Provider Demographics
NPI:1821251497
Name:STALEY, LINDA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ANNE
Last Name:STALEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LONDON AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-5512
Mailing Address - Country:US
Mailing Address - Phone:937-578-2020
Mailing Address - Fax:937-578-2019
Practice Address - Street 1:500 LONDON AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-5512
Practice Address - Country:US
Practice Address - Phone:937-578-2020
Practice Address - Fax:937-578-2019
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0994842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066853Medicaid
OH0066853Medicaid