Provider Demographics
NPI:1437818135
Name:GREEN, STACY RENEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:RENEE
Last Name:GREEN
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 1:9712 E 69TH ST
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-5945
Mailing Address - Country:US
Mailing Address - Phone:816-213-4601
Mailing Address - Fax:
Practice Address - Street 1:1100 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-1572
Practice Address - Country:US
Practice Address - Phone:913-297-9945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021029668363L00000X
KS5380729022363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner