Provider Demographics
NPI:1518360973
Name:WHITAKER, STACEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8439 CROSSLAND LOOP
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-8485
Mailing Address - Country:US
Mailing Address - Phone:334-409-9242
Mailing Address - Fax:334-409-1986
Practice Address - Street 1:8439 CROSSLAND LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-8485
Practice Address - Country:US
Practice Address - Phone:334-409-4292
Practice Address - Fax:334-409-9186
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA1494363A00000X
SCPA2588363A00000X
FLPA9108162363A00000X
GAPA8247363A00000X
CAPA54126363A00000X
VA011006326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant