Provider Demographics
NPI:1083933626
Name:MORMOL, STACEY A (CRNA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:MORMOL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:13515 BARRETT PARKWAY DR STE 170
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5870
Mailing Address - Country:US
Mailing Address - Phone:314-775-2816
Mailing Address - Fax:
Practice Address - Street 1:1015 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2394
Practice Address - Country:US
Practice Address - Phone:636-496-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123598207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology