1710096532 NPI number — STACEY F MAINER ARNP

Table of content: STACEY F MAINER ARNP (NPI 1710096532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710096532 NPI number — STACEY F MAINER ARNP

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAINER
Provider Other First Name:
STACEY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710096532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3867
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99220-3867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-688-6700
Provider Business Mailing Address Fax Number:
509-688-6777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
546 N JEFFERSON LN
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-688-6700
Provider Business Practice Location Address Fax Number:
509-455-6913
Provider Enumeration Date:
08/29/2006

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: 363L00000X , with the licence number:  AP30007446 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9649781 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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