Provider Demographics
NPI:1578105367
Name:BAST, STACEY MARIE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:BAST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MARIE
Other - Last Name:COFFEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:153 CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-1755
Mailing Address - Country:US
Mailing Address - Phone:618-559-3482
Mailing Address - Fax:
Practice Address - Street 1:223 GARDEN ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1974
Practice Address - Country:US
Practice Address - Phone:314-420-9576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-13
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043-087181164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse