Provider Demographics
NPI:1528160173
Name:KINGSLAND, STACY M (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:KINGSLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 15TH AVE S STE 201
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4334
Mailing Address - Country:US
Mailing Address - Phone:406-727-2121
Mailing Address - Fax:
Practice Address - Street 1:401 15TH AVE S STE 201
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4334
Practice Address - Country:US
Practice Address - Phone:406-727-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT10884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine