Provider Demographics
NPI:1508939505
Name:CONNORS, STACIE R (NP)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:R
Last Name:CONNORS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-1931
Mailing Address - Country:US
Mailing Address - Phone:406-563-8500
Mailing Address - Fax:406-563-8694
Practice Address - Street 1:305 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-1900
Practice Address - Country:US
Practice Address - Phone:406-563-7337
Practice Address - Fax:406-563-8338
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN23715363LF0000X
MT100302363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1508939505OtherNPI
MT100302OtherSTATE LICENSE
MT1508938505Medicaid