Provider Demographics
NPI:1598202962
Name:WHITLEY, STACIE LYNN (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:WHITLEY
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 1:3440 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-3803
Mailing Address - Country:US
Mailing Address - Phone:409-833-6900
Mailing Address - Fax:409-833-6908
Practice Address - Street 1:3440 FANNIN ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3803
Practice Address - Country:US
Practice Address - Phone:409-833-6900
Practice Address - Fax:409-833-6908
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily