Provider Demographics
NPI:1538199468
Name:LONGNECKER, STACY MARIE (MD)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:MARIE
Last Name:LONGNECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:WEEDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:450 EASTVOLD AVE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1252
Mailing Address - Country:US
Mailing Address - Phone:320-839-6157
Mailing Address - Fax:
Practice Address - Street 1:450 EASTVOLD AVE
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1252
Practice Address - Country:US
Practice Address - Phone:320-839-6157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine