1508330903 NPI number — STACEY KATHERYN LUNDQUIST LGPC

Table of content: STACEY KATHERYN LUNDQUIST LGPC (NPI 1508330903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508330903 NPI number — STACEY KATHERYN LUNDQUIST LGPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDQUIST
Provider First Name:
STACEY
Provider Middle Name:
KATHERYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LGPC
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:
1508330903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7316 BRAMBLEBUSH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20707-9514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-532-8486
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3060 MICHELLVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
BOWIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-893-4600
Provider Business Practice Location Address Fax Number:
443-640-4358
Provider Enumeration Date:
01/18/2019

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: 101Y00000X , with the licence number:  LGP8365 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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