Provider Demographics
NPI:1487491932
Name:UPTON, STACY JO
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:UPTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28115 LILY ST NW
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-5995
Mailing Address - Country:US
Mailing Address - Phone:763-238-9261
Mailing Address - Fax:
Practice Address - Street 1:28115 LILY ST NW
Practice Address - Street 2:
Practice Address - City:ISANTI
Practice Address - State:MN
Practice Address - Zip Code:55040-5995
Practice Address - Country:US
Practice Address - Phone:763-238-9261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNAS779871171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications