Provider Demographics
NPI:1760164412
Name:FISKE, STACY LEANN (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LEANN
Last Name:FISKE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20067 BEARCLAW RD
Mailing Address - Street 2:
Mailing Address - City:EUNICE
Mailing Address - State:MO
Mailing Address - Zip Code:65468-6804
Mailing Address - Country:US
Mailing Address - Phone:417-247-0677
Mailing Address - Fax:
Practice Address - Street 1:17959 MAIN STREET
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:MO
Practice Address - Zip Code:65466
Practice Address - Country:US
Practice Address - Phone:573-226-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023030046363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner