Provider Demographics
NPI:1760956312
Name:KREGER, STACY RAE (AGNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:RAE
Last Name:KREGER
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:RAE
Other - Last Name:STITZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0043
Mailing Address - Country:US
Mailing Address - Phone:154-181-3150
Mailing Address - Fax:541-813-1506
Practice Address - Street 1:524 SPRUCE ST STE 5
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-0407
Practice Address - Country:US
Practice Address - Phone:541-813-1505
Practice Address - Fax:541-813-1506
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201900396363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty