Provider Demographics
NPI:1558834713
Name:TA, STACEY MAI (MPH, RD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MAI
Last Name:TA
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 VIA CARTAGO APT 45
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6296
Mailing Address - Country:US
Mailing Address - Phone:661-932-6590
Mailing Address - Fax:
Practice Address - Street 1:500 SANSOME ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94111-3215
Practice Address - Country:US
Practice Address - Phone:888-987-8337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator