Provider Demographics
NPI:1528363322
Name:MACKELPRANG, STACY (RN, BSN)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:MACKELPRANG
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:MACKELPRANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:4353 E BLUE HERON LN
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-6054
Mailing Address - Country:US
Mailing Address - Phone:928-567-6772
Mailing Address - Fax:
Practice Address - Street 1:167 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0600
Practice Address - Country:US
Practice Address - Phone:928-283-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN079684163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse