Provider Demographics
NPI:1326172289
Name:WIRTANEN, STACEY LYN (DC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LYN
Last Name:WIRTANEN
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 1:1606 BAYRAM DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-3216
Mailing Address - Country:US
Mailing Address - Phone:713-468-7510
Mailing Address - Fax:
Practice Address - Street 1:1961 W T C JESTER BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1256
Practice Address - Country:US
Practice Address - Phone:713-868-3223
Practice Address - Fax:713-868-1413
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6607111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor