Provider Demographics
NPI:1134760911
Name:CARGILL, STACY LYNN (LPN)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:CARGILL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1976
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321-1976
Mailing Address - Country:US
Mailing Address - Phone:360-829-6162
Mailing Address - Fax:253-829-3391
Practice Address - Street 1:240 N C ST
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:WA
Practice Address - Zip Code:98321-8044
Practice Address - Country:US
Practice Address - Phone:360-829-6162
Practice Address - Fax:253-829-3391
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00031720164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse