Provider Demographics
NPI:1235535535
Name:WARDEN, STACEY MICHELE (WHNP)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MICHELE
Last Name:WARDEN
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505582
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5582
Mailing Address - Country:US
Mailing Address - Phone:314-993-7009
Mailing Address - Fax:314-993-1535
Practice Address - Street 1:10806 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7773
Practice Address - Country:US
Practice Address - Phone:314-993-7009
Practice Address - Fax:314-993-1535
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001006665363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420095602Medicaid