Provider Demographics
NPI:1659903243
Name:BLACKWELL, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BLACKWELL
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 1:5760 CHICOPEE AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1305
Mailing Address - Country:US
Mailing Address - Phone:323-369-8389
Mailing Address - Fax:
Practice Address - Street 1:5760 CHICOPEE AVE
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1305
Practice Address - Country:US
Practice Address - Phone:323-369-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula