Provider Demographics
NPI:1679183172
Name:MCCALLY, STACIE TERESA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:TERESA
Last Name:MCCALLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12167 SHERIDAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12167 SHERIDAN BLVD
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2417
Practice Address - Country:US
Practice Address - Phone:303-658-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-09
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF05200856363LF0000X
COAPN.0995946-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily