Provider Demographics
NPI:1073756268
Name:BRISCOE, STACIA N (CNP)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:N
Last Name:BRISCOE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4038
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:
Practice Address - Street 1:133 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KAHOKA
Practice Address - State:MO
Practice Address - Zip Code:63445-1775
Practice Address - Country:US
Practice Address - Phone:660-727-3388
Practice Address - Fax:660-727-2196
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008011837363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL127510004Medicare PIN