Provider Demographics
NPI:1700393766
Name:VIGIL, STACY JAQUE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JAQUE
Last Name:VIGIL
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 1:1264 RODEO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6816
Mailing Address - Country:US
Mailing Address - Phone:505-982-2129
Mailing Address - Fax:
Practice Address - Street 1:213 CHICO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-9511
Practice Address - Country:US
Practice Address - Phone:505-429-5508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-29
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPN-22383164X00000X, 164W00000X
171M00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty