Provider Demographics
NPI:1083112304
Name:KOONTZ, STACIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:KOONTZ
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 1:4551 FAIRMONT PIKE RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-7615
Mailing Address - Country:US
Mailing Address - Phone:304-233-2625
Mailing Address - Fax:
Practice Address - Street 1:2101 JACOB ST STE 502
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3800
Practice Address - Country:US
Practice Address - Phone:304-234-8476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN68719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily