Provider Demographics
NPI:1366642860
Name:SPECK, STACY M (RD, RN, APN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:SPECK
Suffix:
Gender:F
Credentials:RD, RN, APN
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1500 DETROIT AVE APT 618
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-2448
Mailing Address - Country:US
Mailing Address - Phone:419-564-2927
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE RM B501
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-5741
Practice Address - Fax:216-844-5710
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209006587363LP0200X
OH.0032134363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics