Provider Demographics
NPI:1437197340
Name:STACKIEWICZ, LUCILLE (CRNP)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:
Last Name:STACKIEWICZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:
Other - Last Name:STACKIEWICZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-0206
Mailing Address - Fax:410-328-5685
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-0206
Practice Address - Fax:410-328-5685
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR150477363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000802800Medicaid
DE1000021440Medicaid
WV7105116000Medicaid
MD608331-01OtherBLUE CROSS/BLUE SHIELD
MDS01540RRMedicare PIN
P17327Medicare UPIN
MD608331-01OtherBLUE CROSS/BLUE SHIELD