Provider Demographics
NPI:1942757034
Name:WALKER, STACIE RENEE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:RENEE
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 LAKE BOONE TRL STE 311
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7514
Mailing Address - Country:US
Mailing Address - Phone:919-351-8253
Mailing Address - Fax:
Practice Address - Street 1:4414 LAKE BOONE TRL STE 311
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607
Practice Address - Country:US
Practice Address - Phone:919-351-8253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC617367A00000X
NC224107367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife