Provider Demographics
NPI:1043892920
Name:CASSIDY, STACI LEIGH (NP)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:LEIGH
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:LEIGH
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:843-337-7553
Mailing Address - Fax:
Practice Address - Street 1:1268 S 4TH ST
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-0703
Practice Address - Country:US
Practice Address - Phone:843-332-3422
Practice Address - Fax:843-332-3985
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24579363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCL032OtherMEDICARE
SCNP7760Medicaid