Healthcare Provider Details

I. General information

NPI: 1164865465
Provider Name (Legal Business Name): STACY LEA DEVOL CCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MATTHEW ST STE 401
MARIETTA OH
45750-1656
US

IV. Provider business mailing address

416 COLEGATE DR BLDG 3
MARIETTA OH
45750-9549
US

V. Phone/Fax

Practice location:
  • Phone: 740-374-2252
  • Fax: 740-374-4974
Mailing address:
  • Phone: 740-568-4814
  • Fax: 740-374-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License NumberAPRN.CNS.13383
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License NumberCOA.13383-NS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: