Provider Demographics
NPI:1821367327
Name:STACY, PAMELA RENEE (ACNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:RENEE
Last Name:STACY
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:8288 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5262
Practice Address - Country:US
Practice Address - Phone:903-606-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP121213363L00000X, 363LA2100X, 363LF0000X
TX729458363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-118OtherTRICARE
TX293825001Medicaid
TX75-2616977-007OtherTRICARE
TX867N10OtherBCBS
TX75-2616977-066OtherTRICARE
TX752616977042OtherTRICARE
TXTXB145202Medicare Oscar/Certification
TX867N10OtherBCBS