Provider Demographics
NPI:1437997368
Name:TAM, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:TAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 GATEWICK DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-5645
Mailing Address - Country:US
Mailing Address - Phone:317-353-4273
Mailing Address - Fax:
Practice Address - Street 1:1454 GATEWICK DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-5645
Practice Address - Country:US
Practice Address - Phone:317-353-4273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program