Provider Demographics
NPI:1639517519
Name:ALLEN, STACI NOEL (DO)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:NOEL
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 HAWTHORNE CT UNIT B
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-7975
Mailing Address - Country:US
Mailing Address - Phone:405-831-2195
Mailing Address - Fax:
Practice Address - Street 1:147 HAWTHORNE CT UNIT B
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-7975
Practice Address - Country:US
Practice Address - Phone:405-831-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-128975207LP3000X
ARE11407207LP3000X
ARE-11407207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0143216Medicaid