Healthcare Provider Details

I. General information

NPI: 1902301468
Provider Name (Legal Business Name): STACEY TWIGG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACEY SMITH

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4995 BRADENTON AVE STE 130
DUBLIN OH
43017-3551
US

IV. Provider business mailing address

4995 BRADENTON AVE STE 130
DUBLIN OH
43017-3551
US

V. Phone/Fax

Practice location:
  • Phone: 614-580-6917
  • Fax:
Mailing address:
  • Phone: 614-580-6917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1450509
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number472924
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0032697
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: