Provider Demographics
NPI:1548204183
Name:HENNER WALDEN, STACEY (DO)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:HENNER WALDEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:HENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:57 WATER ST
Mailing Address - Street 2:
Mailing Address - City:BLUE HILL
Mailing Address - State:ME
Mailing Address - Zip Code:04614-5231
Mailing Address - Country:US
Mailing Address - Phone:207-374-2311
Mailing Address - Fax:207-374-3991
Practice Address - Street 1:57 WATER ST
Practice Address - Street 2:
Practice Address - City:BLUE HILL
Practice Address - State:ME
Practice Address - Zip Code:04614-5231
Practice Address - Country:US
Practice Address - Phone:207-374-2311
Practice Address - Fax:207-374-3991
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO1879207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1548204183Medicaid
I36303Medicare UPIN
ME431896299Medicaid
MEME1440Medicare PIN