Healthcare Provider Details

I. General information

NPI: 1043467467
Provider Name (Legal Business Name): STACY MCKEEGAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 CHAMBLISS RD
MEMPHIS TN
38116-6381
US

IV. Provider business mailing address

7705 LYNX RUN CV
CORDOVA TN
38016-5700
US

V. Phone/Fax

Practice location:
  • Phone: 901-348-2273
  • Fax: 901-345-8499
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number3056
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: