Provider Demographics
NPI:1174152557
Name:MCCONICO, STACEY DELENE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:DELENE
Last Name:MCCONICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 EAST LIBERTY STREET
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150
Mailing Address - Country:US
Mailing Address - Phone:803-757-1238
Mailing Address - Fax:803-757-1238
Practice Address - Street 1:201 EAST LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150
Practice Address - Country:US
Practice Address - Phone:803-757-1238
Practice Address - Fax:803-757-1238
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion