Provider Demographics
NPI:1063037828
Name:LAURENCE, STACIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:LAURENCE
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 1:5159 WINCHELL RD
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255-9614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26110 EMERY RD STE 300
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-5788
Practice Address - Country:US
Practice Address - Phone:440-368-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.413742163W00000X
OHAPRN.CNP.027128363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse