Provider Demographics
NPI:1003066085
Name:BACON, STACEY E (NP-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:E
Last Name:BACON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-5856
Mailing Address - Country:US
Mailing Address - Phone:620-235-4452
Mailing Address - Fax:
Practice Address - Street 1:1701 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-5856
Practice Address - Country:US
Practice Address - Phone:620-235-4452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004015211363LF0000X
KS75561363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2004015211OtherMO LICENSE