Provider Demographics
NPI:1770819708
Name:CARPENTER, STACEY L (DO)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:L
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 JOLIET RD
Mailing Address - Street 2:
Mailing Address - City:COUNTRYSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3956
Mailing Address - Country:US
Mailing Address - Phone:708-485-2273
Mailing Address - Fax:708-352-0845
Practice Address - Street 1:6150 JOLIET RD
Practice Address - Street 2:
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525-3956
Practice Address - Country:US
Practice Address - Phone:708-485-2273
Practice Address - Fax:708-352-0845
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134169207Q00000X
MI5101019877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C16002OtherMEDICARE GROUP PTAN