Provider Demographics
NPI:1851957948
Name:RICKLEY, STACIE MARIE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:MARIE
Last Name:RICKLEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 FRANKLIN STREET
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4109
Mailing Address - Country:US
Mailing Address - Phone:814-534-9230
Mailing Address - Fax:
Practice Address - Street 1:1265 NEW GERMANY RD
Practice Address - Street 2:
Practice Address - City:SUMMERHILL
Practice Address - State:PA
Practice Address - Zip Code:15958-5301
Practice Address - Country:US
Practice Address - Phone:814-244-2939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN547989207V00000X
PAMW010546367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherN/A