Provider Demographics
NPI:1891336319
Name:STACY, TARA MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:STACY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 BELMONT DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-4926
Mailing Address - Country:US
Mailing Address - Phone:423-646-0002
Mailing Address - Fax:
Practice Address - Street 1:1360 DOLLY PARTON PKWY
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-3715
Practice Address - Country:US
Practice Address - Phone:865-429-0921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-06
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000026102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner