Healthcare Provider Details

I. General information

NPI: 1821378027
Provider Name (Legal Business Name): STACY LADEANE FORD WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2712 MIDDLEBURG DR SUITE 107
COLUMBIA SC
29204-2415
US

IV. Provider business mailing address

100 S BOYLAN AVE
RALEIGH NC
27603-1802
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-4908
  • Fax: 803-256-4900
Mailing address:
  • Phone: 919-833-7526
  • Fax: 919-832-9061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberFOR104269443
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN102954
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4036
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: