Provider Demographics
NPI:1598048894
Name:HOLLOWAY, STACIE DIANNE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:DIANNE
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:STACIE
Other - Middle Name:WARD
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1024 CANTWELL PL
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-2756
Mailing Address - Country:US
Mailing Address - Phone:662-882-3722
Mailing Address - Fax:
Practice Address - Street 1:1604 WESTGATE CIR STE 240
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8578
Practice Address - Country:US
Practice Address - Phone:615-652-1489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ016585Medicaid