Provider Demographics
NPI:1700564291
Name:CHANG, STACY ANNETTE (BSN, RN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ANNETTE
Last Name:CHANG
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E 30TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8805
Mailing Address - Country:US
Mailing Address - Phone:505-324-9840
Mailing Address - Fax:
Practice Address - Street 1:2200 N SUNSET AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3421
Practice Address - Country:US
Practice Address - Phone:505-324-0352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR36591163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool