Provider Demographics
NPI:1669036976
Name:WALNER, STACI J (NP)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:J
Last Name:WALNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12761 N EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9429
Mailing Address - Country:US
Mailing Address - Phone:208-704-6655
Mailing Address - Fax:
Practice Address - Street 1:12761 N EMERALD DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9429
Practice Address - Country:US
Practice Address - Phone:208-704-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID61171363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner