Provider Demographics
NPI:1649372202
Name:CLANCY, STACEY LYNN (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:CLANCY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10345 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127
Mailing Address - Country:US
Mailing Address - Phone:314-965-6033
Mailing Address - Fax:314-965-6067
Practice Address - Street 1:10345 WATSON RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127
Practice Address - Country:US
Practice Address - Phone:314-965-6033
Practice Address - Fax:314-965-6067
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112661207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO95124OtherMEDICARE NUMBER 95124
MO95124OtherMEDICARE NUMBER 95124
MOH33559Medicare PIN