Provider Demographics
NPI:1659719706
Name:ANDERSON, STACY RENEE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:RENEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:RENEE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:520 WILKES DR STE 13
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-4854
Mailing Address - Country:US
Mailing Address - Phone:307-212-6862
Mailing Address - Fax:307-212-2246
Practice Address - Street 1:520 WILKES DR STE 13
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-4854
Practice Address - Country:US
Practice Address - Phone:307-212-6242
Practice Address - Fax:307-212-2246
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY18512.1248363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY842269506Medicaid
WY453160445Medicaid