Provider Demographics
NPI:1750653291
Name:GREENUP, STACEY M (PPCNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:GREENUP
Suffix:
Gender:F
Credentials:PPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 GARFIELD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-2527
Mailing Address - Country:US
Mailing Address - Phone:304-893-9090
Mailing Address - Fax:304-893-9113
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:NATIONWIDE CHILDREN'S HOSPITAL-CTICU
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-9042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2011009651363LP0200X
WVAPRN86910-PPCNP-BC363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810028858Medicaid