Provider Demographics
NPI:1578980413
Name:SHAKEL, STACEY LEE
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LEE
Last Name:SHAKEL
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 1:3525 YBARRA RD
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91978-1117
Mailing Address - Country:US
Mailing Address - Phone:619-564-9652
Mailing Address - Fax:
Practice Address - Street 1:1465 30TH ST
Practice Address - Street 2:SUITE K
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3497
Practice Address - Country:US
Practice Address - Phone:619-428-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA278803164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse