Provider Demographics
NPI:1326394891
Name:HOUSHOLDER, STACIE L (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:HOUSHOLDER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:L
Other - Last Name:TODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004055A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner