Provider Demographics
NPI:1275515181
Name:AGEE, STACEY ANN (ANP)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANN
Last Name:AGEE
Suffix:
Gender:F
Credentials:ANP
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 176
Mailing Address - Street 2:
Mailing Address - City:WHEELER
Mailing Address - State:OR
Mailing Address - Zip Code:97147-0176
Mailing Address - Country:US
Mailing Address - Phone:800-368-5182
Mailing Address - Fax:844-717-0711
Practice Address - Street 1:2120 EXCHANGE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3365
Practice Address - Country:US
Practice Address - Phone:503-325-5360
Practice Address - Fax:503-325-9373
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087006402N3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR239443Medicaid
OR133792Medicare PIN
OR239443Medicaid