Provider Demographics
NPI:1982915187
Name:COLEMAN, STACY (IDMT)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 SHERMAN CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2923
Mailing Address - Country:US
Mailing Address - Phone:301-705-5327
Mailing Address - Fax:
Practice Address - Street 1:1002 SHERMAN CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2923
Practice Address - Country:US
Practice Address - Phone:301-705-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians