Provider Demographics
NPI:1841771839
Name:STACEY, PATRICIA (LPN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:STACEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 HIGHWAY 14 W
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-1037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:607 4TH ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1278
Practice Address - Country:US
Practice Address - Phone:618-273-2951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043071374164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse