Provider Demographics
NPI:1215219431
Name:PAUL, STACY JO (MA 60239038)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:PAUL
Suffix:
Gender:F
Credentials:MA 60239038
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 FINNEGAN WAY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-6622
Mailing Address - Country:US
Mailing Address - Phone:360-527-9566
Mailing Address - Fax:360-527-8534
Practice Address - Street 1:1112 FINNEGAN WAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-6622
Practice Address - Country:US
Practice Address - Phone:360-527-9566
Practice Address - Fax:360-527-8534
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60239038172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker