Provider Demographics
NPI:1700399805
Name:WHALEN, STACEY R (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:R
Last Name:WHALEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 1ST ST STE 410
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8306
Mailing Address - Country:US
Mailing Address - Phone:478-743-7068
Mailing Address - Fax:478-741-1354
Practice Address - Street 1:800 1ST ST STE 410
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8306
Practice Address - Country:US
Practice Address - Phone:478-743-7068
Practice Address - Fax:478-741-1354
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216180363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily