Provider Demographics
NPI:1538878301
Name:BLACKWELL, STACEY MICHELE (CHC)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MICHELE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:CHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 SIOUX AVE
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-2679
Mailing Address - Country:US
Mailing Address - Phone:760-401-1568
Mailing Address - Fax:
Practice Address - Street 1:6801 SIOUX AVE
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-2679
Practice Address - Country:US
Practice Address - Phone:760-401-1568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach