Provider Demographics
NPI:1790079812
Name:ANDERSON, STACIE DYAN (DPM)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:DYAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-2633
Mailing Address - Country:US
Mailing Address - Phone:440-884-4100
Mailing Address - Fax:440-884-4742
Practice Address - Street 1:5625 RIDGE RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-2633
Practice Address - Country:US
Practice Address - Phone:440-884-4100
Practice Address - Fax:440-884-4742
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003622213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery