Provider Demographics
NPI:1851841498
Name:WINDHAM, STACEY (ND)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WINDHAM
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14635 SW QUAIL LN APT N103
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-7670
Mailing Address - Country:US
Mailing Address - Phone:513-313-1494
Mailing Address - Fax:
Practice Address - Street 1:049 SW PORTER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4848
Practice Address - Country:US
Practice Address - Phone:503-552-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4022175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath