Healthcare Provider Details

I. General information

NPI: 1578530697
Provider Name (Legal Business Name): STACEY E. O'KINSELLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E KINCAID ST URGENT CARE
MOUNT VERNON WA
98274-4127
US

IV. Provider business mailing address

1400 E KINCAID ST ATTN: CREDENTIALING
MOUNT VERNON WA
98274-4127
US

V. Phone/Fax

Practice location:
  • Phone: 360-428-6434
  • Fax: 360-848-4233
Mailing address:
  • Phone: 360-428-2500
  • Fax: 360-428-6485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37544
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00037544
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: