Provider Demographics
NPI:1184225096
Name:MOON, STACEY (APRN, MNSC, AGACNPBC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:APRN, MNSC, AGACNPBC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 SPRINGHILL DR STE 200A
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-2948
Mailing Address - Country:US
Mailing Address - Phone:501-413-9290
Mailing Address - Fax:
Practice Address - Street 1:3500 SPRINGHILL DR STE 200A
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2948
Practice Address - Country:US
Practice Address - Phone:501-413-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR124009363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care