Provider Demographics
NPI:1477756674
Name:MORTENSEN, STACEY MAE (DC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:MAE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:DC
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 28
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:ND
Mailing Address - Zip Code:58784-0028
Mailing Address - Country:US
Mailing Address - Phone:701-628-7246
Mailing Address - Fax:
Practice Address - Street 1:108 S MAIN ST
Practice Address - Street 2:BOX 28
Practice Address - City:STANLEY
Practice Address - State:ND
Practice Address - Zip Code:58784
Practice Address - Country:US
Practice Address - Phone:701-628-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND744111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN24075Medicare ID - Type Unspecified
NDU98952Medicare UPIN