Provider Demographics
NPI:1992002067
Name:MOTT, STACEY (MSN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MOTT
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 UNION UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3780
Mailing Address - Country:US
Mailing Address - Phone:731-215-1281
Mailing Address - Fax:731-215-1281
Practice Address - Street 1:1340 UNION UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3780
Practice Address - Country:US
Practice Address - Phone:731-215-1281
Practice Address - Fax:731-215-1281
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15611363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily