Healthcare Provider Details

I. General information

NPI: 1003771114
Provider Name (Legal Business Name): STACEY K DOUWES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47915 OASIS ST
INDIO CA
92201-6950
US

IV. Provider business mailing address

1207 PALMAS RDG
PALM SPRINGS CA
92262-1259
US

V. Phone/Fax

Practice location:
  • Phone: 760-835-5601
  • Fax:
Mailing address:
  • Phone: 760-835-5601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: