Provider Demographics
NPI:1568962843
Name:STACY, JENNIFER (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 BLOUNTVILLE HWY STE 105
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1676
Mailing Address - Country:US
Mailing Address - Phone:423-797-5505
Mailing Address - Fax:423-797-4486
Practice Address - Street 1:350 BLOUNTVILLE HWY STE 105
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1676
Practice Address - Country:US
Practice Address - Phone:423-797-5504
Practice Address - Fax:423-797-4486
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23778363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ036117Medicaid