Provider Demographics
NPI:1710990775
Name:ANDERSON, STACEY LEA (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:MCLELLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-0468
Mailing Address - Country:US
Mailing Address - Phone:207-474-7131
Mailing Address - Fax:207-474-3998
Practice Address - Street 1:46 FAIRVIEW AVE STE 229
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1481
Practice Address - Country:US
Practice Address - Phone:207-474-7131
Practice Address - Fax:207-474-3998
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5227207VX0000X
MEMD22365207VX0000X
MEEL181026207VX0000X
WA60858413207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1710990775Medicaid
AKI04382Medicare UPIN
AKMD6072Medicaid