Provider Demographics
NPI:1912187329
Name:NELSON, STACEY LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:NELSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W FOREST AVE STE 117
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1482
Mailing Address - Country:US
Mailing Address - Phone:928-773-2505
Mailing Address - Fax:928-773-2504
Practice Address - Street 1:77 W FOREST AVE STE 117
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1482
Practice Address - Country:US
Practice Address - Phone:928-773-2505
Practice Address - Fax:928-773-2504
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ078032367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ295431Medicaid
AZ295431Medicaid
AZ119456Medicare PIN
AZZ119456Medicare PIN