Provider Demographics
NPI:1790741072
Name:STACY, MARY JAEGER (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JAEGER
Last Name:STACY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5957 MAIN STREET
Mailing Address - Street 2:NORTHSHIRE MEDICAL CENTER
Mailing Address - City:MANCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05255
Mailing Address - Country:US
Mailing Address - Phone:802-362-4440
Mailing Address - Fax:802-362-7146
Practice Address - Street 1:5957 MAIN ST
Practice Address - Street 2:NORTHSHIRE MEDICAL CENTER
Practice Address - City:MANCHESTER CENTER
Practice Address - State:VT
Practice Address - Zip Code:05255-8913
Practice Address - Country:US
Practice Address - Phone:802-362-4440
Practice Address - Fax:802-362-7146
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0019775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0NP1782Medicaid
VTNP178203Medicare PIN