Provider Demographics
NPI:1598146631
Name:KING, STACEY (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21141 STATE HIGHWAY 59 STE 1
Mailing Address - Street 2:
Mailing Address - City:ROBERTSDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36567-6740
Mailing Address - Country:US
Mailing Address - Phone:251-424-1160
Mailing Address - Fax:251-424-1161
Practice Address - Street 1:21141 STATE HIGHWAY 59 STE 1
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567-6740
Practice Address - Country:US
Practice Address - Phone:251-424-1160
Practice Address - Fax:251-424-1161
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-103735363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL207558Medicaid
AL248107Medicaid