Provider Demographics
NPI:1033275946
Name:LEVISON, STACEY (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:LEVISON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2782 COBB PKWY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3472
Mailing Address - Country:US
Mailing Address - Phone:770-590-8181
Mailing Address - Fax:
Practice Address - Street 1:2782 COBB PKWY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3472
Practice Address - Country:US
Practice Address - Phone:770-590-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN160089363LF0000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA228231227AMedicaid