Provider Demographics
NPI:1891758181
Name:STALEY, NANCY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:STALEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2939
Mailing Address - Country:US
Mailing Address - Phone:508-832-7118
Mailing Address - Fax:508-832-4758
Practice Address - Street 1:55 BEACH ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2728
Practice Address - Country:US
Practice Address - Phone:401-475-9140
Practice Address - Fax:401-475-9143
Is Sole Proprietor?:No
Enumeration Date:2006-04-09
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00286363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0000027594OtherBCBS RI
RI411588OtherBLUE CHIP RI
RI9004837Medicaid
RI290000286RI01OtherANTHEM CT
CT200286OtherCONNECTICARE
RI290000286RI01OtherANTHEM CT