Healthcare Provider Details

I. General information

NPI: 1649372202
Provider Name (Legal Business Name): STACEY LYNN CLANCY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS STACEY L MURRAY

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10345 WATSON RD
ST LOUIS MO
63127
US

IV. Provider business mailing address

10345 WATSON RD
ST LOUIS MO
63127
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-6033
  • Fax: 314-965-6067
Mailing address:
  • Phone: 314-965-6033
  • Fax: 314-965-6067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number112661
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: