Provider Demographics
NPI:1285299206
Name:CHACKO-STACEY, ALEXANDRA ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:ELIZABETH
Last Name:CHACKO-STACEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1760 E KEN PRATT BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-5311
Practice Address - Country:US
Practice Address - Phone:720-718-8222
Practice Address - Fax:720-718-0954
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0071257207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program