Provider Demographics
NPI:1740233030
Name:STACY, EVELYN M (ARNP)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:M
Last Name:STACY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HITCHCOCK WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-4125
Mailing Address - Country:US
Mailing Address - Phone:603-695-2750
Mailing Address - Fax:
Practice Address - Street 1:100 HITCHCOCK WAY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-4125
Practice Address - Country:US
Practice Address - Phone:603-695-2500
Practice Address - Fax:603-898-4779
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH029942-23364SP0807X, 363LP0200X
NHRN 02994221163WP0808X
NHAR NP 0299422308363LP0200X
NHAR NP 0299422302363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30009223Medicaid
NH30009223Medicaid