Provider Demographics
NPI:1083713473
Name:KERR, STACEY MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:MARIE
Last Name:KERR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3344 CYPRESS WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7514
Mailing Address - Country:US
Mailing Address - Phone:707-526-2540
Mailing Address - Fax:
Practice Address - Street 1:3344 CYPRESS WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7514
Practice Address - Country:US
Practice Address - Phone:707-526-2540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG069395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF26278Medicare UPIN