Provider Demographics
NPI:1346006632
Name:ELLMAN, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ELLMAN
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 1:132 STATE RD E
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01473-1209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:132 STATE RD E
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01473-1209
Practice Address - Country:US
Practice Address - Phone:978-895-9625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6047156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician