Provider Demographics
NPI:1235380064
Name:DETMER, STACIE D (FNP)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:D
Last Name:DETMER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:D
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:314-851-4445
Practice Address - Street 1:1011 BOWLES AVE STE 450
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-0562
Practice Address - Country:US
Practice Address - Phone:314-467-1500
Practice Address - Fax:314-467-1515
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005018747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1245100004Medicare PIN