Provider Demographics
NPI:1629428891
Name:KNOWLES, STACY (LPN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KNOWLES
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 1:2630 WAYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1324
Mailing Address - Country:US
Mailing Address - Phone:402-875-0792
Mailing Address - Fax:
Practice Address - Street 1:2630 WAYSIDE LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1324
Practice Address - Country:US
Practice Address - Phone:402-875-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201603472LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse