Provider Demographics
NPI:1265490585
Name:LEIFRIED, STACY (APRN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LEIFRIED
Suffix:
Gender:F
Credentials:APRN
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-579-3297
Mailing Address - Fax:702-800-8235
Practice Address - Street 1:2716 N TENAYA WAY
Practice Address - Street 2:4TH FLOOR
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-877-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN17354163W00000X
NVAPRN00419363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1265490585Medicaid
NV105706Medicare PIN
NVV112023Medicare PIN
NVFZ528ZMedicare PIN
NVFZ528YMedicare PIN