Provider Demographics
NPI:1023286416
Name:HANCOCK, STACEY (LMP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3005
Mailing Address - Country:US
Mailing Address - Phone:360-367-0321
Mailing Address - Fax:
Practice Address - Street 1:1534 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3005
Practice Address - Country:US
Practice Address - Phone:360-367-0321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012688174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist