Provider Demographics
NPI:1710939301
Name:HOPPER, STACYE (APN)
Entity Type:Individual
Prefix:
First Name:STACYE
Middle Name:
Last Name:HOPPER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BOSWELL ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-3097
Mailing Address - Country:US
Mailing Address - Phone:731-249-5020
Mailing Address - Fax:
Practice Address - Street 1:250 BOSWELL ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-3097
Practice Address - Country:US
Practice Address - Phone:731-249-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT100792363LF0000X
TN6005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1710939301Medicaid