Provider Demographics
NPI:1407294846
Name:MATERN, STACEY (DC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MATERN
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 1:4741 REGENT AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3740
Mailing Address - Country:US
Mailing Address - Phone:651-341-9194
Mailing Address - Fax:
Practice Address - Street 1:1444 147TH AVE NE
Practice Address - Street 2:SUITE 250
Practice Address - City:HAM LAKE
Practice Address - State:MN
Practice Address - Zip Code:55304-4971
Practice Address - Country:US
Practice Address - Phone:763-208-5382
Practice Address - Fax:763-208-2911
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor