Healthcare Provider Details

I. General information

NPI: 1316064512
Provider Name (Legal Business Name): STACY LEILANI WHITAKER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 SW 3RD AVE STE 3200
ONTARIO OR
97914-4560
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 541-881-2325
  • Fax: 208-914-6701
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDO150653
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number11323
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: