Provider Demographics
NPI:1023213329
Name:EUBANKS, STACIE SMITH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:SMITH
Last Name:EUBANKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-3318
Mailing Address - Country:US
Mailing Address - Phone:612-225-1512
Mailing Address - Fax:
Practice Address - Street 1:920 2ND AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-3318
Practice Address - Country:US
Practice Address - Phone:612-225-1512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3251363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA26419090Medicare PIN