Provider Demographics
NPI:1366856536
Name:GUTIERREZ, STACY MARIE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20003 MAHOGANY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77355-4996
Mailing Address - Country:US
Mailing Address - Phone:443-955-9836
Mailing Address - Fax:
Practice Address - Street 1:20003 MAHOGANY RIDGE DR
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77355-4996
Practice Address - Country:US
Practice Address - Phone:443-955-9836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX898509133V00000X
TX754202163W00000X
TX202997163WL0100X
TXAP142069363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant