Provider Demographics
NPI:1780943886
Name:ALLEN, STACEY LYNN (MT)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LYNN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 RUSH DR
Mailing Address - Street 2:#27
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-7950
Mailing Address - Country:US
Mailing Address - Phone:760-613-4363
Mailing Address - Fax:
Practice Address - Street 1:950 BOARDWALK
Practice Address - Street 2:STE. 304
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2600
Practice Address - Country:US
Practice Address - Phone:760-613-4363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5378172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12363328OtherCAQH
CA5378OtherCAMTC
CA967160OtherABMP