Provider Demographics
NPI:1073208757
Name:BURDETT, STACEY MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:BURDETT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42543 PARK CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-7533
Mailing Address - Country:US
Mailing Address - Phone:406-360-4263
Mailing Address - Fax:406-883-5555
Practice Address - Street 1:126 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-2600
Practice Address - Country:US
Practice Address - Phone:406-676-3600
Practice Address - Fax:406-676-3738
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID75899363LF0000X
MT214369363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily