Provider Demographics
NPI:1912134289
Name:THOMPSON, STACY ELLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:ELLEN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:90 MILLBURN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1945
Mailing Address - Country:US
Mailing Address - Phone:973-378-7990
Mailing Address - Fax:973-378-7991
Practice Address - Street 1:90 MILLBURN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1945
Practice Address - Country:US
Practice Address - Phone:973-378-7990
Practice Address - Fax:973-378-7991
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08604800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics