Provider Demographics
NPI:1083388359
Name:EDGAR, STACY LEE (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEE
Last Name:EDGAR
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 COUNTY ROAD 607
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5544
Mailing Address - Country:US
Mailing Address - Phone:573-300-9971
Mailing Address - Fax:
Practice Address - Street 1:2360 KATY LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2300
Practice Address - Country:US
Practice Address - Phone:573-712-2546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021026192363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily