Provider Demographics
NPI:1518139617
Name:ANDERSON, STACY M (PMHNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PMHNP
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 278
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071
Mailing Address - Country:US
Mailing Address - Phone:971-983-5260
Mailing Address - Fax:971-983-5326
Practice Address - Street 1:1475 MT. HOOD AVE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071
Practice Address - Country:US
Practice Address - Phone:971-983-5214
Practice Address - Fax:971-983-5219
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850153NPPMHNP-PP364SP0808X
OR200850153NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673539Medicaid
OR500601826Medicaid
ORR145037Medicare PIN