Provider Demographics
NPI:1730481243
Name:SHERWOOD, STACY JO (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:STACY JO
Middle Name:
Last Name:SHERWOOD
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 ELDORADO AVE.
Mailing Address - Street 2:
Mailing Address - City:KLAMTH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6418
Mailing Address - Country:US
Mailing Address - Phone:541-883-1030
Mailing Address - Fax:541-884-2338
Practice Address - Street 1:725 WASHBURN WAY
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-3648
Practice Address - Country:US
Practice Address - Phone:541-883-1030
Practice Address - Fax:541-884-2338
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223354Medicaid