Provider Demographics
NPI:1629308531
Name:CHILTON, STACY MAE (DC)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:MAE
Last Name:CHILTON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MAE
Other - Last Name:BUNDROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:811 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2462
Mailing Address - Country:US
Mailing Address - Phone:360-423-3482
Mailing Address - Fax:
Practice Address - Street 1:811 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2462
Practice Address - Country:US
Practice Address - Phone:360-423-3482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60106639111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor