Provider Demographics
NPI:1437169992
Name:ZELLER, STACY HOLSTON (MD)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:HOLSTON
Last Name:ZELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3444 MASONIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301
Mailing Address - Country:US
Mailing Address - Phone:318-473-9556
Mailing Address - Fax:318-441-8310
Practice Address - Street 1:3444 MASONIC DRIVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301
Practice Address - Country:US
Practice Address - Phone:318-473-9556
Practice Address - Fax:318-441-8310
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023932207Q00000X
LAMD023932207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1555835Medicaid
LA1555835Medicaid
LA5H780F600Medicare ID - Type Unspecified