1124440383 NPI number — STACEY MARTINELLI

Table of content: STACEY MARTINELLI (NPI 1124440383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124440383 NPI number — STACEY MARTINELLI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINELLI
Provider First Name:
STACEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124440383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17700 W CAPITOL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53045-2006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-781-3083
Provider Business Mailing Address Fax Number:
262-781-3080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4772 KATELLA AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LOS ALAMITOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90720-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-430-8700
Provider Business Practice Location Address Fax Number:
562-430-8760
Provider Enumeration Date:
01/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  6611 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 1782 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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