Provider Demographics
NPI:1790081941
Name:MERRITT, STACY LANE (NP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LANE
Last Name:MERRITT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 DECLARATION BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-8139
Mailing Address - Country:US
Mailing Address - Phone:803-905-3278
Mailing Address - Fax:803-905-3282
Practice Address - Street 1:3440 DECLARATION BLVD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154-8139
Practice Address - Country:US
Practice Address - Phone:803-905-3278
Practice Address - Fax:803-905-3282
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4456363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1124180732OtherFASTER CARE NPI
SC1124180732OtherFASTER CARE NPI