Provider Demographics
NPI:1952309981
Name:PURCELL, STACY L (PA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:PURCELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2028
Mailing Address - Country:US
Mailing Address - Phone:815-791-9553
Mailing Address - Fax:630-495-1770
Practice Address - Street 1:123 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-2028
Practice Address - Country:US
Practice Address - Phone:815-860-0757
Practice Address - Fax:708-923-2529
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85002282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK13605Medicare PIN
ILQ32337Medicare UPIN