Healthcare Provider Details

I. General information

NPI: 1871133488
Provider Name (Legal Business Name): STACIA HUFFMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2020
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 WREN DR
NEW MARTINSVILLE WV
26155-2832
US

IV. Provider business mailing address

1234 WREN DR
NEW MARTINSVILLE WV
26155-2832
US

V. Phone/Fax

Practice location:
  • Phone: 740-213-9051
  • Fax:
Mailing address:
  • Phone: 740-213-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF12190801
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number106009
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: