Provider Demographics
NPI:1528412624
Name:SPROULL, STACEY R (ARNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:SPROULL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 SE 8TH AVE STE 108A
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4253
Mailing Address - Country:US
Mailing Address - Phone:503-494-8417
Mailing Address - Fax:503-494-4455
Practice Address - Street 1:364 SE 8TH AVE STE 108A
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4253
Practice Address - Country:US
Practice Address - Phone:503-494-8417
Practice Address - Fax:503-494-4455
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9165986363L00000X
WAAP61272607363LA2200X
OR10018726363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1528412624Medicaid