Provider Demographics
NPI:1083985840
Name:HARVEY, STACEY MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:HARVEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MICHELLE
Other - Last Name:WARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:7584 OLIVE BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-1600
Mailing Address - Country:US
Mailing Address - Phone:314-203-9349
Mailing Address - Fax:314-480-7069
Practice Address - Street 1:7584 OLIVE BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-1600
Practice Address - Country:US
Practice Address - Phone:314-203-9349
Practice Address - Fax:314-480-7069
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000156514164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO473367076OtherTIN