Provider Demographics
NPI:1174139471
Name:HERRING, STACIE LEANN
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:LEANN
Last Name:HERRING
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 1:8200 S QUEBEC ST # A3-516
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-4411
Mailing Address - Country:US
Mailing Address - Phone:850-832-5360
Mailing Address - Fax:
Practice Address - Street 1:1300 TX-107
Practice Address - Street 2:
Practice Address - City:LA VILLA
Practice Address - State:TX
Practice Address - Zip Code:78562
Practice Address - Country:US
Practice Address - Phone:956-262-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ247176207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine