Provider Demographics
NPI:1447987227
Name:STACEY H WILLIFORD LLC
Entity type:Organization
Organization Name:STACEY H WILLIFORD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:478-232-7066
Mailing Address - Street 1:601 FERNCREST DR STE 2
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-1892
Mailing Address - Country:US
Mailing Address - Phone:478-412-2880
Mailing Address - Fax:478-412-2881
Practice Address - Street 1:601 FERNCREST DR STE 2
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1892
Practice Address - Country:US
Practice Address - Phone:478-412-2880
Practice Address - Fax:478-412-2881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty