Provider Demographics
NPI:1992028138
Name:RAE, STACY (LAC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RAE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 BLACKFOOT TRL
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-9720
Mailing Address - Country:US
Mailing Address - Phone:970-209-8310
Mailing Address - Fax:970-641-5364
Practice Address - Street 1:320 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2404
Practice Address - Country:US
Practice Address - Phone:970-209-8310
Practice Address - Fax:970-641-5364
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO843171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist