Provider Demographics
NPI:1659820264
Name:RELLER, STACY (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RELLER
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 CHICAGO AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4387
Mailing Address - Country:US
Mailing Address - Phone:612-813-3300
Mailing Address - Fax:612-813-3349
Practice Address - Street 1:2530 CHICAGO AVE STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-813-3300
Practice Address - Fax:612-813-3349
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4769363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care