Provider Demographics
NPI:1477757086
Name:WHITESIDE, STACY (RN MS CPNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:RN MS CPNP
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Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-3254
Mailing Address - Fax:614-722-4574
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-3254
Practice Address - Fax:614-722-4574
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHRN248329 NP06037163WP0218X
OHCOA06037NP363LP2300X
OHAPRN.CNP.06037363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0218XNursing Service ProvidersRegistered NursePediatric Oncology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3028619Medicaid