Provider Demographics
NPI:1952363616
Name:NIPP, STACEY ANN (DPM)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:NIPP
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANN
Other - Last Name:KINDIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:324 W SUPERIOR ST
Mailing Address - Street 2:STE 408
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802
Mailing Address - Country:US
Mailing Address - Phone:218-722-0615
Mailing Address - Fax:218-722-6712
Practice Address - Street 1:324 W SUPERIOR ST
Practice Address - Street 2:STE 408
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802
Practice Address - Country:US
Practice Address - Phone:218-722-0615
Practice Address - Fax:218-722-6712
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN482213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN014725700Medicaid
5B969N0OtherBCBS
U32429Medicare UPIN
489000156Medicare ID - Type Unspecified