Basic Information
| Provider Information | |||||||||
| NPI: | 1093725566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8701 CUYAMACA ST | ||||||||
| Address2: | |||||||||
| City: | SANTEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584992715 | ||||||||
| FaxNumber: | 6195688080 | ||||||||
| Practice Location | |||||||||
| Address1: | 8701 CUYAMACA ST | ||||||||
| Address2: | |||||||||
| City: | SANTEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584992715 | ||||||||
| FaxNumber: | 6195688080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A6527 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX65270 | 05 | CA | MEDICAID |