Provider Demographics
NPI:1417693029
Name:WALDEN, STACY B
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:B
Last Name:WALDEN
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 1:1025 E CROSS ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3987
Mailing Address - Country:US
Mailing Address - Phone:734-483-0628
Mailing Address - Fax:
Practice Address - Street 1:1025 E CROSS ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3987
Practice Address - Country:US
Practice Address - Phone:734-483-0628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health