Provider Demographics
NPI:1376845073
Name:MC DOWELL, STACY L (CNS)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:MC DOWELL
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR STE 312
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1073
Practice Address - Country:US
Practice Address - Phone:574-647-5200
Practice Address - Fax:574-647-5210
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003872A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000769085OtherBCBS BMG VASCULAR INTERVENTIONAL RAD
IN201006430Medicaid
INP01146029OtherRR MEDICARE
INM400069347Medicare PIN