Healthcare Provider Details

I. General information

NPI: 1790116002
Provider Name (Legal Business Name): STACIE BARRETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 RHOMBOID PL
BELVEDERE SC
29841-2635
US

IV. Provider business mailing address

201 RHOMBOID PL
BELVEDERE SC
29841-2635
US

V. Phone/Fax

Practice location:
  • Phone: 803-442-6330
  • Fax:
Mailing address:
  • Phone: 803-442-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number214152
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: