Provider Demographics
NPI:1497775167
Name:LINCK, STACEY L (CRNA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:LINCK
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 1:2929 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8034
Mailing Address - Country:US
Mailing Address - Phone:602-470-5000
Mailing Address - Fax:602-470-5064
Practice Address - Street 1:1850 N CENTRAL AVE STE 1600
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4633
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:602-262-4132
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001016542367500000X
AZCRNA1221367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910997501Medicaid
MOP00391447OtherRAILROAD MEDICARE
MOP00391447OtherRAILROAD MEDICARE
IL$$$$$$$$$001OtherIL DEPT OF HEALTHCARE
MO910997501Medicaid