Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | 036-142803 | IL |
N | 207YP0228X | Pediatric Otolaryngology | 036-142803 | IL |
NPI | 1336436435 |
---|---|
Provider Name | Stacie Renee Gregory |
First Address | Springfield, IL 62701-1041 |
Second Address | Springfield, IL 62701-1041 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2011 |
Last Update Date | 26/10/2020 |