Provider Demographics
NPI:1255415451
Name:ALI, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ALI
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:PO BOX 740018
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0018
Mailing Address - Country:US
Mailing Address - Phone:773-352-1517
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:5555 ZUNI RD SE STE 11
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2935
Practice Address - Country:US
Practice Address - Phone:505-777-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP3006906363LF0000X
NM67604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44609736Medicaid
AZ936057Medicaid
AZ936057Medicaid