Provider Demographics
NPI:1407061856
Name:LARGE, STACIE RAE (RN)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:RAE
Last Name:LARGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:STACIE
Other - Middle Name:RAE
Other - Last Name:KIDD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2700 S 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-4059
Mailing Address - Country:US
Mailing Address - Phone:913-758-3792
Mailing Address - Fax:913-758-3788
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-100760-112163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse