Provider Demographics
NPI:1235370891
Name:STAM, NANCY PELLEGRINO (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:PELLEGRINO
Last Name:STAM
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23070
Mailing Address - Street 2:
Mailing Address - City:BARLING
Mailing Address - State:AR
Mailing Address - Zip Code:72923-0070
Mailing Address - Country:US
Mailing Address - Phone:479-452-5040
Mailing Address - Fax:479-452-5047
Practice Address - Street 1:1340 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2556
Practice Address - Country:US
Practice Address - Phone:479-452-5040
Practice Address - Fax:479-452-5047
Is Sole Proprietor?:No
Enumeration Date:2009-03-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO048363L00000X
CO148363LP0808X
VA2010005264363LP0808X
ARA004937364SP0810X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health