Provider Demographics
NPI:1639409824
Name:COMMODORE, STACY LYN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYN
Last Name:COMMODORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:BLANKENSHIP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3466
Mailing Address - Country:US
Mailing Address - Phone:304-720-8816
Mailing Address - Fax:904-494-6467
Practice Address - Street 1:2000 MON HEALTH MEDICAL PARK DR STE 2001
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1167
Practice Address - Country:US
Practice Address - Phone:304-720-8816
Practice Address - Fax:904-494-6467
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV62855367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV270052997001OtherTRICARE NORTH
WV9333201OtherMEDICARE GROUP
WV270052997OtherSELECT NET
WV270052997004OtherTRICARE NORTH
WV3810016716Medicaid
WV0207026000OtherMEDICAID GROUP
WVP00843679OtherRAILROAD MEDICARE
OH3019307OtherOHIO MEDICAID
WV9333201OtherMEDICARE GROUP