Provider Demographics
NPI:1558890806
Name:HIBDON, STACEY MARIE
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MARIE
Last Name:HIBDON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:MARIE
Other - Last Name:BAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1010 OLD DES PERES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1865
Mailing Address - Country:US
Mailing Address - Phone:314-729-0077
Mailing Address - Fax:
Practice Address - Street 1:1010 OLD DES PERES RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1865
Practice Address - Country:US
Practice Address - Phone:314-729-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016044203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily