Provider Demographics
NPI:1558405142
Name:PFENNING, STACEY (DNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:PFENNING
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5675
Mailing Address - Country:US
Mailing Address - Phone:701-222-3937
Mailing Address - Fax:701-222-8805
Practice Address - Street 1:200 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5675
Practice Address - Country:US
Practice Address - Phone:701-222-3937
Practice Address - Fax:701-222-8805
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR27350363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1451286Medicaid
ND19750Medicaid
ND500028258OtherRR MEDICARE
NDR27350OtherLICENSE
P74334Medicare UPIN
NDN22453Medicare PIN