Provider Demographics
NPI:1871936542
Name:BARKSDALE, STACEY ALEXANDER
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ALEXANDER
Last Name:BARKSDALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 CARIBE PL
Mailing Address - Street 2:838 CARIBE PLACE
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1151
Mailing Address - Country:US
Mailing Address - Phone:757-362-7822
Mailing Address - Fax:
Practice Address - Street 1:838 CARIBE PL
Practice Address - Street 2:838 CARIBE PLACE
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1151
Practice Address - Country:US
Practice Address - Phone:757-362-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA60542664172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver