Provider Demographics
NPI:1487682274
Name:BOONE-VIKINGSON, STACY MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:MARIE
Last Name:BOONE-VIKINGSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2501 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1602
Mailing Address - Country:US
Mailing Address - Phone:952-855-5444
Mailing Address - Fax:952-886-7561
Practice Address - Street 1:2501 W 84TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1602
Practice Address - Country:US
Practice Address - Phone:952-885-5444
Practice Address - Fax:952-886-7561
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4815111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN44-03165OtherMEDICA
MN701555OtherOPTIMUM HEALTH
MN469667900Medicaid
MN09N91BOOtherBLUE CROSS BLUE SHIELD OF MINNESOTA
MN469667900Medicaid