Provider Demographics
NPI:1164440111
Name:MAXWELL-KROCKENBERGER, STACEY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ANN
Last Name:MAXWELL-KROCKENBERGER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HICKORY RIDGE DRIVE
Mailing Address - Street 2:SUITE #800
Mailing Address - City:HILLSBORO
Mailing Address - State:MO
Mailing Address - Zip Code:63050-3264
Mailing Address - Country:US
Mailing Address - Phone:636-797-5100
Mailing Address - Fax:636-797-2745
Practice Address - Street 1:4 HICKORY RIDGE DRIVE
Practice Address - Street 2:SUITE #800
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-3264
Practice Address - Country:US
Practice Address - Phone:636-797-5100
Practice Address - Fax:636-797-2745
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005005613111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO710707OtherHEALTHLINK - NON-PAR
MO199263OtherBCBS