Healthcare Provider Details

I. General information

NPI: 1902131709
Provider Name (Legal Business Name): STACIE LYNN MANDEVILLE CLD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 10/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 THOMPSON PIKE
DAYVILLE CT
06241-1116
US

IV. Provider business mailing address

168 THOMPSON PIKE
DAYVILLE CT
06241-1116
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-7725
  • Fax: 860-774-7725
Mailing address:
  • Phone: 860-774-7725
  • Fax: 860-774-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: