Healthcare Provider Details

I. General information

NPI: 1760469175
Provider Name (Legal Business Name): STACEY MACKAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 PARK NICOLLET BLVD PARK NICOLLET CLINIC - SLP
ST LOUIS PARK MN
55416
US

IV. Provider business mailing address

6465 WAYZATA BLVD STE 315
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3025
  • Fax: 952-993-1937
Mailing address:
  • Phone: 952-993-7169
  • Fax: 952-993-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41342
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: