Provider Demographics
NPI:1164626826
Name:DENNISON, STACIA A (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:STACIA
Middle Name:A
Last Name:DENNISON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:A
Other - Last Name:FALLERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4653
Mailing Address - Country:US
Mailing Address - Phone:217-868-2812
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:1303 W EVERGREEN AVE STE 200
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1638
Practice Address - Country:US
Practice Address - Phone:217-342-3400
Practice Address - Fax:217-342-3477
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041346618163WM0705X
IL209015810363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner