Provider Demographics
NPI:1417200072
Name:STUBBLEFIELD, PANCHAPON IVY (LAC)
Entity Type:Individual
Prefix:
First Name:PANCHAPON
Middle Name:IVY
Last Name:STUBBLEFIELD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1570
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92033-1570
Mailing Address - Country:US
Mailing Address - Phone:760-215-0551
Mailing Address - Fax:760-317-1827
Practice Address - Street 1:333 S JUNIPER ST
Practice Address - Street 2:SUITE 111
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4924
Practice Address - Country:US
Practice Address - Phone:760-215-0551
Practice Address - Fax:760-317-1827
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15049171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist