Healthcare Provider Details

I. General information

NPI: 1376543991
Provider Name (Legal Business Name): STACY J CONWAY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 BALTIMORE DR
WILKES BARRE PA
18702-7900
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

V. Phone/Fax

Practice location:
  • Phone: 570-808-5441
  • Fax: 570-808-5371
Mailing address:
  • Phone: 570-808-5441
  • Fax: 570-808-5371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001254
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: