Provider Demographics
NPI:1710096532
Name:MAINER, STACEY F (ARNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:F
Last Name:MAINER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:MAINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 3867
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3867
Mailing Address - Country:US
Mailing Address - Phone:509-688-6700
Mailing Address - Fax:509-688-6777
Practice Address - Street 1:546 N JEFFERSON LN
Practice Address - Street 2:SUITE 200
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201
Practice Address - Country:US
Practice Address - Phone:509-688-6700
Practice Address - Fax:509-455-6913
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007446363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9649781Medicaid