Provider Demographics
NPI:1417500307
Name:ROYALL, STACY D (NP-BC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:D
Last Name:ROYALL
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:D
Other - Last Name:GODDARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:916 KESSLER MILL RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3048
Mailing Address - Country:US
Mailing Address - Phone:540-505-8530
Mailing Address - Fax:
Practice Address - Street 1:401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-1588
Practice Address - Country:US
Practice Address - Phone:540-961-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177404363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner