Provider Demographics
NPI:1962510222
Name:NELSON, STACY D (NP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:D
Last Name:NELSON
Suffix:
Gender:F
Credentials:NP
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 1261
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-6261
Mailing Address - Country:US
Mailing Address - Phone:607-547-3772
Mailing Address - Fax:607-547-3259
Practice Address - Street 1:701 SUPERIOR AVE STE E
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4038
Practice Address - Country:US
Practice Address - Phone:219-922-7159
Practice Address - Fax:219-922-4020
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320064363L00000X
IN71008745A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner