Provider Demographics
NPI:1164163077
Name:ALT, STACEY FAYE (CNM, WHNP-BC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:FAYE
Last Name:ALT
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 CAMINO DE LA REINA UNIT 106
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-5523
Mailing Address - Country:US
Mailing Address - Phone:619-643-1197
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:619-643-1197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236252176B00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife