Provider Demographics
NPI:1760775357
Name:DAULT, STACEY LOUISE (DO)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LOUISE
Last Name:DAULT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:LOUISE
Other - Last Name:WETMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 6085
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-6085
Mailing Address - Country:US
Mailing Address - Phone:480-846-0688
Mailing Address - Fax:
Practice Address - Street 1:6139 S RURAL RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2929
Practice Address - Country:US
Practice Address - Phone:480-846-0688
Practice Address - Fax:480-741-8650
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006185207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ030026Medicaid