Healthcare Provider Details

I. General information

NPI: 1306733324
Provider Name (Legal Business Name): MS. STACY NORVELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6641 N HIGH ST STE 104
WORTHINGTON OH
43085-4038
US

IV. Provider business mailing address

5055 ROLLING ROCK CT
COLUMBUS OH
43229-4783
US

V. Phone/Fax

Practice location:
  • Phone: 614-885-2000
  • Fax:
Mailing address:
  • Phone: 614-226-6459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number123456
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: