Provider Demographics
NPI:1144597816
Name:SULLIVAN, STACEY MIGLICCO (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MIGLICCO
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8926 FOREST CREEK DR APT 174
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-5161
Mailing Address - Country:US
Mailing Address - Phone:817-368-5334
Mailing Address - Fax:
Practice Address - Street 1:1400 WOODLOCH FOREST DR STE 575
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-1179
Practice Address - Country:US
Practice Address - Phone:281-528-1523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-24
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX731774363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health