Provider Demographics
NPI:1619314549
Name:HYDRICK, STACY L (LPN)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:L
Last Name:HYDRICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N BENTON ST
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:IL
Mailing Address - Zip Code:61088-8354
Mailing Address - Country:US
Mailing Address - Phone:815-391-4684
Mailing Address - Fax:
Practice Address - Street 1:310 N BENTON ST
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:IL
Practice Address - Zip Code:61088-8354
Practice Address - Country:US
Practice Address - Phone:815-391-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-01
Last Update Date:2013-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.106224164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse