Provider Demographics
NPI:1851814875
Name:HUDSON, STACI LEA (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:LEA
Last Name:HUDSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MS
Other - First Name:STACI
Other - Middle Name:LEA
Other - Last Name:LUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2705 HWY 51 SOUTH
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632
Mailing Address - Country:US
Mailing Address - Phone:662-449-1971
Mailing Address - Fax:
Practice Address - Street 1:2705 HWY 51 SOUTH
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632
Practice Address - Country:US
Practice Address - Phone:662-449-1971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902167363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health