Provider Demographics
NPI:1497185284
Name:BROWN, STACEY M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:BROWN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 MATTHEW ST STE 303
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1656
Practice Address - Country:US
Practice Address - Phone:740-373-7828
Practice Address - Fax:740-373-5898
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010977363LF0000X
OHAPRN.CNP.15612363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098594Medicaid
WV3810027179Medicaid
OHH291701Medicare PIN
WV3810027179Medicaid