MEDICARE: DR. STACIE NWABUEZE PHD

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	225400000X	Rehabilitation Practitioner	LRC-790	LA

General Provider Information

NPI Number	:	1619353406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACIE NWABUEZE PHD

Provider Business Mailing Address
First Line	:	3050 CHARLES DR
Second Line	:
City	:	JACKSON
State	:	LA
Zip	:	70748-6135
Country	:	US
Telephone Number	:	225-634-3517
Fax Number	:	225-634-5057

Provider Business Practice Location Address
First Line	:	3050 CHARLES DR
Second Line	:
City	:	JACKSON
State	:	LA
Zip	:	70748-6135
Country	:	US
Telephone Number	:	225-634-3517
Fax Number	:	225-634-5057

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

Provider Enumeration Date	:	08/04/2015
Last Update Date	:	08/04/2015

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Directions to “ DR. STACIE NWABUEZE PHD” Practice Location

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