MEDICARE: STACY EDO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	342000000X	Transportation Network Company		LA

General Provider Information

NPI Number	:	1285329755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY EDO

Provider Business Mailing Address
First Line	:	7357 CHERRYDALE DR
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70706-1956
Country	:	US
Telephone Number	:	225-277-2022
Fax Number	:

Provider Business Practice Location Address
First Line	:	7357 CHERRYDALE DR
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70706-1956
Country	:	US
Telephone Number	:	225-277-2022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2023
Last Update Date	:	04/10/2023

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Directions to “ STACY EDO ” Practice Location

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