Healthcare Provider Details

I. General information

NPI: 1922241165
Provider Name (Legal Business Name): STACY M TELLONI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 MACON POND RD
RALEIGH NC
27607-6319
US

IV. Provider business mailing address

PO BOX 63362
CHARLOTTE NC
28263-3362
US

V. Phone/Fax

Practice location:
  • Phone: 919-862-5400
  • Fax:
Mailing address:
  • Phone: 919-684-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number2012-00277
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: