Provider Demographics
NPI:1609523760
Name:DIMARTINO, STACY RENEE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:RENEE
Last Name:DIMARTINO
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 1:16451 LAWSON VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:JAMUL
Mailing Address - State:CA
Mailing Address - Zip Code:91935-2413
Mailing Address - Country:US
Mailing Address - Phone:619-246-1551
Mailing Address - Fax:
Practice Address - Street 1:16451 LAWSON VALLEY RD
Practice Address - Street 2:
Practice Address - City:JAMUL
Practice Address - State:CA
Practice Address - Zip Code:91935-2413
Practice Address - Country:US
Practice Address - Phone:619-246-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4459050OtherDRIVER LICENSE