Provider Demographics
NPI:1710163456
Name:CARDA, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CARDA
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 1:341 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6208
Mailing Address - Country:US
Mailing Address - Phone:208-342-8180
Mailing Address - Fax:
Practice Address - Street 1:341 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6208
Practice Address - Country:US
Practice Address - Phone:208-342-8180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID100543246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist