=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710670492
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACEY DIAN STANCIL PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2023
-----------------------------------------------------
Last Update Date | 05/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 SILVERWOOD CT STE 100
-----------------------------------------------------
City | RINCON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31326-5131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-826-3927
-----------------------------------------------------
Fax | 912-826-3931
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 228 CLEARWATER CIR
-----------------------------------------------------
City | PORT WENTWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31407-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-437-8260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 11643
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------