1952363616 NPI number — STACEY ANN NIPP DPM

Table of content: STACEY ANN NIPP DPM (NPI 1952363616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952363616 NPI number — STACEY ANN NIPP DPM

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KINDIG
Provider Other First Name:
STACEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1952363616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 W SUPERIOR ST
Provider Second Line Business Mailing Address:
STE 408
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-722-0615
Provider Business Mailing Address Fax Number:
218-722-6712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 W SUPERIOR ST
Provider Second Line Business Practice Location Address:
STE 408
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-722-0615
Provider Business Practice Location Address Fax Number:
218-722-6712
Provider Enumeration Date:
04/06/2006

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: 213E00000X , with the licence number:  482 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: 482 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 014725700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5B969N0 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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