Provider Demographics
NPI:1689404105
Name:ROSE-DIXON, STACIE L (MED)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:ROSE-DIXON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 318
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10919-0318
Mailing Address - Country:US
Mailing Address - Phone:508-335-4509
Mailing Address - Fax:
Practice Address - Street 1:11504 JAMESTOWN CT
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-2054
Practice Address - Country:US
Practice Address - Phone:301-960-7884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program