Provider Demographics
NPI:1689902595
Name:GODMAN, STACEY LYNN (CRNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:GODMAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 BRADFORD CT
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-4810
Mailing Address - Country:US
Mailing Address - Phone:610-935-4608
Mailing Address - Fax:
Practice Address - Street 1:12 GILL ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1765
Practice Address - Country:US
Practice Address - Phone:781-939-7397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010635363L00000X
PARN546954163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse