Provider Demographics
NPI:1447389796
Name:BRAGG, STACY ALLISON (OD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ALLISON
Last Name:BRAGG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 KINGSPORT WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-5247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7901 WATT AVE
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-2000
Practice Address - Country:US
Practice Address - Phone:916-332-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12909152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist