Provider Demographics
NPI:1740090836
Name:MCDERMOTT, STACY ROSE
Entity type:Individual
Prefix:MISS
First Name:STACY
Middle Name:ROSE
Last Name:MCDERMOTT
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 1:455 16TH AVE SE APT 217
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-2620
Mailing Address - Country:US
Mailing Address - Phone:563-581-9641
Mailing Address - Fax:
Practice Address - Street 1:3601 16TH AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-2363
Practice Address - Country:US
Practice Address - Phone:319-390-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist