Provider Demographics
NPI:1417099565
Name:BASKERVILLE, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BASKERVILLE
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 1:300 SILVERLEAF RD APT 1201
Mailing Address - Street 2:
Mailing Address - City:SWEENY
Mailing Address - State:TX
Mailing Address - Zip Code:77480-1839
Mailing Address - Country:US
Mailing Address - Phone:979-482-4637
Mailing Address - Fax:
Practice Address - Street 1:300 SILVERLEAF RD APT 1201
Practice Address - Street 2:
Practice Address - City:SWEENY
Practice Address - State:TX
Practice Address - Zip Code:77480-1839
Practice Address - Country:US
Practice Address - Phone:979-482-4637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139905146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1824609Medicaid
TX1824609Medicaid