Provider Demographics
NPI:1114930658
Name:CHURCH, STACY ANNETTE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANNETTE
Last Name:CHURCH
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 1:3100 MACCORKLE AVE SE
Mailing Address - Street 2:SUITE 610
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1223
Mailing Address - Country:US
Mailing Address - Phone:304-346-1141
Mailing Address - Fax:
Practice Address - Street 1:3100 MACCORKLE AVE SE
Practice Address - Street 2:SUITE 610
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1223
Practice Address - Country:US
Practice Address - Phone:304-346-1141
Practice Address - Fax:304-346-1142
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01163363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical