Provider Demographics
NPI:1952301848
Name:WHITE, STACEY L (DPM)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:WHITE
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 1:7250 FRANCE AVE S
Mailing Address - Street 2:SUITE # 415
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4305
Mailing Address - Country:US
Mailing Address - Phone:952-926-3566
Mailing Address - Fax:952-929-3358
Practice Address - Street 1:7250 FRANCE AVE S
Practice Address - Street 2:SUITE # 415
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4305
Practice Address - Country:US
Practice Address - Phone:952-926-3566
Practice Address - Fax:952-929-3358
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN595213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN595OtherPODIATRIC LICENSE
MN595OtherPODIATRIC LICENSE