Provider Demographics
NPI:1184862096
Name:RICHARDSON, STACY (RN,MSN,FNP-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:RN,MSN,FNP-C
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:J
Other - Last Name:GROOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 ASSOCIATION DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1298
Mailing Address - Country:US
Mailing Address - Phone:304-388-0151
Mailing Address - Fax:304-388-1721
Practice Address - Street 1:3100 MACCORKLE AVE SE STE 900
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1223
Practice Address - Country:US
Practice Address - Phone:304-388-5880
Practice Address - Fax:304-388-5858
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44522363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014885Medicaid