Provider Demographics
NPI:1891998829
Name:CALLAGHAN, STACEY LYNN (LM,CPM,ICCE,CD,CLE)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:CALLAGHAN
Suffix:
Gender:F
Credentials:LM,CPM,ICCE,CD,CLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 FRENCH RD NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:360-789-9969
Mailing Address - Fax:
Practice Address - Street 1:2731 FRENCH RD NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502
Practice Address - Country:US
Practice Address - Phone:360-789-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
WAMIDW.MW.60473932176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7408206Medicaid