Provider Demographics
NPI:1912204892
Name:GOULET, STACEY LEE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:GOULET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 E BROADWAY BLVD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-2843
Mailing Address - Country:US
Mailing Address - Phone:520-298-9281
Mailing Address - Fax:520-298-9718
Practice Address - Street 1:7030 E BROADWAY BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2843
Practice Address - Country:US
Practice Address - Phone:520-298-9281
Practice Address - Fax:520-298-9718
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZN/A374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide