Provider Demographics
NPI:1942706189
Name:BRANHAM, STACEY CONN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:CONN
Last Name:BRANHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MITCHELL LN
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-8008
Mailing Address - Country:US
Mailing Address - Phone:606-207-6960
Mailing Address - Fax:
Practice Address - Street 1:120 MITCHELL LN
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-8008
Practice Address - Country:US
Practice Address - Phone:606-207-6960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily