Provider Demographics
NPI:1013376946
Name:STACEY, TIFFANY (LMT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:STACEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:SNOWDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 211231
Mailing Address - Street 2:
Mailing Address - City:AUKE BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99821-1231
Mailing Address - Country:US
Mailing Address - Phone:907-738-6369
Mailing Address - Fax:
Practice Address - Street 1:418 HARRIS ST STE 317
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1083
Practice Address - Country:US
Practice Address - Phone:907-738-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-20
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101927225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist