Provider Demographics
NPI:1114102332
Name:CARROLL, STACEY M (PHD, APRN-BC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:M
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PHD, APRN-BC
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:CORDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 WAYLAND CIR
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-2439
Mailing Address - Country:US
Mailing Address - Phone:508-829-7847
Mailing Address - Fax:
Practice Address - Street 1:18 WAYLAND CIR
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-2439
Practice Address - Country:US
Practice Address - Phone:508-829-7847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212620163WG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP1474Medicare UPIN