Provider Demographics
NPI:1134513690
Name:MARTIN, STACEY EDITH (RN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:EDITH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:EDITH
Other - Last Name:PLASCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:486 JEANNIE WAY
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-7224
Mailing Address - Country:US
Mailing Address - Phone:510-299-6822
Mailing Address - Fax:
Practice Address - Street 1:1111 E STANLEY BLVD STE 112
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4115
Practice Address - Country:US
Practice Address - Phone:925-243-1385
Practice Address - Fax:925-243-0127
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95055810163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse