Provider Demographics
NPI:1356188098
Name:WIRTH, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:WIRTH
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 1:5431 ELAINA CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1765
Mailing Address - Country:US
Mailing Address - Phone:702-354-3956
Mailing Address - Fax:
Practice Address - Street 1:5431 ELAINA CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1765
Practice Address - Country:US
Practice Address - Phone:702-354-3956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty