Provider Demographics
NPI:1063479814
Name:GALLION, STACIA (APN)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:GALLION
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8000
Mailing Address - Fax:870-934-3677
Practice Address - Street 1:4808E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8413
Practice Address - Country:US
Practice Address - Phone:870-936-7000
Practice Address - Fax:870-934-3677
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01861363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159864758Medicaid
AR159864758Medicaid
AR5Y376Medicare ID - Type Unspecified