Provider Demographics
NPI:1447653431
Name:FLETCHER, STACEY (IBCLC)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N WALTON BLVD STE 34
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-5175
Mailing Address - Country:US
Mailing Address - Phone:479-936-6119
Mailing Address - Fax:
Practice Address - Street 1:162 E SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2830
Practice Address - Country:US
Practice Address - Phone:479-936-6119
Practice Address - Fax:479-521-4161
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2038124Q00000X
MO2011008416124Q00000X
ARL-142878174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No124Q00000XDental ProvidersDental Hygienist