Provider Demographics
NPI:1073985511
Name:OWENS, STACY (LPN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:OWENS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:
Practice Address - Street 1:2920 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-5924
Practice Address - Country:US
Practice Address - Phone:618-244-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043082639164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse