Provider Demographics
NPI:1013663129
Name:STUBBLEFIELD, TAYLOR ANNE (IDC)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANNE
Last Name:STUBBLEFIELD
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:ANNE
Other - Last Name:MERCADEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IDC
Mailing Address - Street 1:480 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860-4908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:951-442-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program