Provider Demographics
NPI:1710535091
Name:TAVENNER, STACY MARIE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:TAVENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 ANVIL CT
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-8858
Mailing Address - Country:US
Mailing Address - Phone:317-418-5138
Mailing Address - Fax:
Practice Address - Street 1:3001 HUNGARY SPRING RD STE C
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-2428
Practice Address - Country:US
Practice Address - Phone:317-418-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24185330363L00000X
FL11021325363L00000X
GARN212253363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health