Provider Demographics
NPI:1295213650
Name:BLANK, STACY MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:BLANK
Suffix:
Gender:F
Credentials:CNP
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 43
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-625-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-29
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6040363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner