Provider Demographics
NPI:1730858093
Name:INGALLS, STACEY LEE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:INGALLS
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 1:5837 HABER ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-3135
Mailing Address - Country:US
Mailing Address - Phone:619-990-5466
Mailing Address - Fax:
Practice Address - Street 1:5837 HABER ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-3135
Practice Address - Country:US
Practice Address - Phone:619-990-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530683163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse