Provider Demographics
NPI:1578530697
Name:O'KINSELLA, STACEY E (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:E
Last Name:O'KINSELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1400 E KINCAID ST
Practice Address - Street 2:URGENT CARE
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-428-6434
Practice Address - Fax:360-848-4233
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA37544207Q00000X
WAMD00037544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8855399Medicare PIN
WAH58969Medicare UPIN