Provider Demographics
NPI:1972963809
Name:HUMPHREY, STACEY NICOLE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:NICOLE
Last Name:HUMPHREY
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 1:2175 ORLEANS LN
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-2111
Mailing Address - Country:US
Mailing Address - Phone:314-243-1785
Mailing Address - Fax:314-480-7162
Practice Address - Street 1:2175 ORLEANS LN
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-2111
Practice Address - Country:US
Practice Address - Phone:314-243-1785
Practice Address - Fax:314-480-7162
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment