Provider Demographics
NPI:1285891168
Name:REED, STACY NICOLE (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:NICOLE
Last Name:REED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13305 NW CORNELL RD STE C
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5987
Mailing Address - Country:US
Mailing Address - Phone:503-765-5000
Mailing Address - Fax:866-742-0249
Practice Address - Street 1:13305 NW CORNELL RD STE C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5987
Practice Address - Country:US
Practice Address - Phone:503-765-5000
Practice Address - Fax:866-742-0249
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60215670207NS0135X, 207N00000X
ORMD153328207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500646390Medicaid