Provider Demographics
NPI:1487231395
Name:GANTZ, STACY MARIE
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:GANTZ
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 1:2944 GRACEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1667
Mailing Address - Country:US
Mailing Address - Phone:240-778-3997
Mailing Address - Fax:
Practice Address - Street 1:3 POST OFFICE RD STE 105
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2756
Practice Address - Country:US
Practice Address - Phone:301-893-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program