Provider Demographics
NPI:1740425123
Name:STALLARD, GINA L (LMT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:L
Last Name:STALLARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 HEATHER CT
Mailing Address - Street 2:
Mailing Address - City:REEDSPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97467-1919
Mailing Address - Country:US
Mailing Address - Phone:541-361-0121
Mailing Address - Fax:
Practice Address - Street 1:1025 HEATHER CT
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467-1919
Practice Address - Country:US
Practice Address - Phone:541-361-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5871174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5871OtherLICENSE