Provider Demographics
NPI:1477630234
Name:EMBANATO, STACY R (CRNA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:EMBANATO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:P O BOX 1123
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:
Practice Address - Street 1:323 W. WALNUT AVENUE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220
Practice Address - Country:US
Practice Address - Phone:318-343-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04193367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1153893Medicaid
LA4C646CJ33Medicare PIN
LA4C646CF16Medicare ID - Type Unspecified