Provider Demographics
NPI:1558789487
Name:STACY, JOAN E (NP-C)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:E
Last Name:STACY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:E
Other - Last Name:LANGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1108 LAVACA ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-2172
Mailing Address - Country:US
Mailing Address - Phone:512-477-4088
Mailing Address - Fax:
Practice Address - Street 1:1108 LAVACA ST STE 110-320
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2172
Practice Address - Country:US
Practice Address - Phone:512-477-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006812363L00000X
TXAP138688363LG0600X
NC221089363LA2200X
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
SCNP2777Medicaid
NC1558789487Medicaid
NCNCL142AMedicare PIN