Provider Demographics
NPI:1326453473
Name:MCCRAY, STACIE L (NP)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:MCCRAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:365 STOUT DRIVE BOX70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4515
Mailing Address - Fax:423-439-4060
Practice Address - Street 1:152 HIGHWAY 143
Practice Address - Street 2:
Practice Address - City:ROAN MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37687-3002
Practice Address - Country:US
Practice Address - Phone:423-772-3276
Practice Address - Fax:423-772-4816
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024171883363LF0000X
TN18892363LF0000X
TN149505163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVE634BMedicare PIN
TN10350I6754Medicare PIN