Basic Information
| Provider Information | |||||||||
| NPI: | 1306445473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORTEZ | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3606 35TH AVE | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612655430 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 516 E NIZHONI BLVD | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 041.337307 | IL | Y | Nursing Service Providers | Registered Nurse | Emergency |
No ID Information.