Provider Demographics
NPI:1134517279
Name:BROWN, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BROWN
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 1:433 METAIRIE RD
Mailing Address - Street 2:106
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-4333
Mailing Address - Country:US
Mailing Address - Phone:504-835-7554
Mailing Address - Fax:
Practice Address - Street 1:433 METAIRIE RD
Practice Address - Street 2:106
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005-4333
Practice Address - Country:US
Practice Address - Phone:504-835-7554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7782171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA225700000XOtherNPI NUMBER NEEDED