Provider Demographics
NPI:1073158119
Name:TEBBE, STACEY
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:TEBBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COLES CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-9314
Mailing Address - Country:US
Mailing Address - Phone:217-234-5110
Mailing Address - Fax:
Practice Address - Street 1:101 COLES CENTRE DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9314
Practice Address - Country:US
Practice Address - Phone:217-234-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020253363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner