Provider Demographics
NPI:1508254004
Name:MAHINDA, STACY NICLE
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICLE
Last Name:MAHINDA
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 1:41 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:IL
Mailing Address - Zip Code:62684-9524
Mailing Address - Country:US
Mailing Address - Phone:217-415-2596
Mailing Address - Fax:
Practice Address - Street 1:41 KNOLLWOOD DR
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:IL
Practice Address - Zip Code:62684-9524
Practice Address - Country:US
Practice Address - Phone:217-415-2596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program