Provider Demographics
NPI:1437234770
Name:STACK, MARY BETH (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
Last Name:STACK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 B RESERVOIR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901
Mailing Address - Country:US
Mailing Address - Phone:434-978-1361
Mailing Address - Fax:
Practice Address - Street 1:2955 IVY RD
Practice Address - Street 2:SUITE 201 UNIVERSITY OF VIRGINIA HEALTH SYSTEM NORTHRID
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903
Practice Address - Country:US
Practice Address - Phone:434-243-4531
Practice Address - Fax:434-243-4717
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001096552163W00000X
VA0024096552363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
C07038OtherCMS GROUP
500029674OtherRAILROAD
P39395Medicare UPIN
500000941Medicare ID - Type Unspecified