Provider Demographics
NPI:1033736764
Name:STACK, HAILEY DOMINY (PA-C)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:DOMINY
Last Name:STACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6413 WATERS AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2711
Mailing Address - Country:US
Mailing Address - Phone:912-349-6624
Mailing Address - Fax:912-352-4728
Practice Address - Street 1:6413 WATERS AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2711
Practice Address - Country:US
Practice Address - Phone:912-349-6624
Practice Address - Fax:912-352-4728
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant