Provider Demographics
NPI: | 1942891486 |
---|---|
Name: | ABBOTT, STACY (FNP-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | STACY |
Middle Name: | |
Last Name: | ABBOTT |
Suffix: | |
Gender: | F |
Credentials: | FNP-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 1653 |
Mailing Address - Street 2: | |
Mailing Address - City: | SALIDA |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 81201-1652 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 719-239-1673 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1000 RUSH DR |
Practice Address - Street 2: | |
Practice Address - City: | SALIDA |
Practice Address - State: | CO |
Practice Address - Zip Code: | 81201-9627 |
Practice Address - Country: | US |
Practice Address - Phone: | 719-530-2000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2021-01-28 |
Last Update Date: | 2023-10-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CO | 165566 | 163WR0006X |
AK | 180729 | 163WR0006X |
AK | 180792 | 363LF0000X |
CO | 0996383-NP | 363LP2300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No | 163WR0006X | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |