Provider Demographics
NPI:1841442928
Name:MACDONALD, STACY ANN (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANN
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1310
Practice Address - Street 1:516 NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1310
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR65522163W00000X
NY567816163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse