Provider Demographics
NPI:1093185829
Name:WHITWORTH, STACY LYNN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:WHITWORTH
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 1:914 REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-6358
Mailing Address - Country:US
Mailing Address - Phone:803-259-5311
Mailing Address - Fax:803-259-5196
Practice Address - Street 1:914 REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-6358
Practice Address - Country:US
Practice Address - Phone:803-259-5311
Practice Address - Fax:803-259-5196
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA196303363LF0000X
SC21687363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily