Provider Demographics
NPI:1972605699
Name:BURNETT, STACEY A (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:BURNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0550
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7187
Practice Address - Street 1:146 A PASSION PLAY ROAD
Practice Address - Street 2:
Practice Address - City:EUREKA SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72632
Practice Address - Country:US
Practice Address - Phone:479-253-9746
Practice Address - Fax:479-253-2464
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118001207Q00000X
ARE2772207Q00000X
ARE-2772207Q00000X
MO2002019590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP7101328OtherDEA
H66072Medicare UPIN