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General NPI Number Information
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NPI Number | 1104448281
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Entity Type | Individual
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Provider Name | STACEY DARRISAW RN, CCM
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Gender | Female
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Dates
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Enumeration Date | 05/12/2020
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Last Update Date | 05/12/2020
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Provider Practice Location Address
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Address Line | 2020 7TH AVE
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City | COLUMBUS
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State | GA
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Zip | 31904-8914
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Country | US
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Telephone | 762-822-1242
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Fax | 706-494-4445
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Provider Business Mailing Address
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Address Line | 49 WESTWOOD WAY
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City | FORTSON
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State | GA
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Zip | 31808-6069
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Country | US
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Telephone | 762-822-1242
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Fax | 706-494-4445
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WC0400X
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Taxonomy Name | Case Management Registered Nurse
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License Number | RN124631
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | RN124631
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | RN124631
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License Number State | GA
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