Provider Demographics
NPI:1831637529
Name:ANDERSON, STACEY (APRN, FNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8711 VILLAGE DR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5418
Mailing Address - Country:US
Mailing Address - Phone:210-200-6744
Mailing Address - Fax:
Practice Address - Street 1:16088 SAN PEDRO AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2251
Practice Address - Country:US
Practice Address - Phone:210-200-6744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX532011YKRCMedicare PIN