Provider Demographics
NPI:1114298684
Name:GROVES, STACEY LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEIGH
Last Name:GROVES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 SEVEN SPRINGS WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4576
Mailing Address - Country:US
Mailing Address - Phone:615-370-9992
Mailing Address - Fax:615-370-9665
Practice Address - Street 1:317 SEVEN SPRINGS WAY STE 101
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027
Practice Address - Country:US
Practice Address - Phone:615-370-9992
Practice Address - Fax:615-370-9665
Is Sole Proprietor?:No
Enumeration Date:2012-01-15
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I979117Medicare PIN