Provider Demographics
NPI:1386202935
Name:HALL, STACY (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:HALL
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 1:16848 W LAKE HOUSTON PKWY
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-4367
Mailing Address - Country:US
Mailing Address - Phone:832-914-7079
Mailing Address - Fax:
Practice Address - Street 1:19875 SOUTHWEST FWY STE 110
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3502
Practice Address - Country:US
Practice Address - Phone:281-545-2226
Practice Address - Fax:281-545-2231
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAPI140837363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140837Medicaid