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General NPI Number Information
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NPI Number | 1639164247
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Entity Type | Individual
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Provider Name | STACIE R LYNN OD
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Gender | Female
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Dates
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Enumeration Date | 09/20/2005
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Last Update Date | 03/19/2025
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Provider Practice Location Address
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Address Line | 9863 BUSLETON AVE STE A
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City | PHILADELPHIA
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State | PA
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Zip | 19115
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Country | US
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Telephone | 215-969-1100
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Fax |
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Provider Business Mailing Address
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Address Line | 1425 SLOAN WAY
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City | AMBLER
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State | PA
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Zip | 19002-1205
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Country | US
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Telephone | 773-531-5568
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Fax |
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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 | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 046009376
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OEG002050
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046-009376
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License Number State | IL
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