Provider Demographics
NPI:1770592016
Name:PERRY, STACEY L (DPM)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:PERRY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34509 9TH AVE S
Mailing Address - Street 2:STE 306
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6700
Mailing Address - Country:US
Mailing Address - Phone:253-242-5293
Mailing Address - Fax:523-944-4004
Practice Address - Street 1:34509 9TH AVE S
Practice Address - Street 2:STE 306
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6700
Practice Address - Country:US
Practice Address - Phone:253-242-5293
Practice Address - Fax:523-944-4004
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000740213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8423576Medicaid
WAP00354461OtherRAILROAD
WA0196190OtherL & I
WA8905952OtherCRIME VICTIMS
WA8905952OtherCRIME VICTIMS
V05031Medicare UPIN