Provider Demographics
NPI:1114443678
Name:KITCHENS, STACEY NEUBAUER (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:NEUBAUER
Last Name:KITCHENS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 CULLEYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4917
Mailing Address - Country:US
Mailing Address - Phone:601-668-6025
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902210363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty