Provider Demographics
NPI:1659848372
Name:FOOTE, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:FOOTE
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 1:1493 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1047
Mailing Address - Country:US
Mailing Address - Phone:617-665-1000
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:NH
Practice Address - Zip Code:03076-2331
Practice Address - Country:US
Practice Address - Phone:603-508-7332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program