Provider Demographics
NPI:1013300896
Name:ANDERSON, STACEY M (APRN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MUIR
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7906
Mailing Address - Fax:
Practice Address - Street 1:107 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:KY
Practice Address - Zip Code:40311-1150
Practice Address - Country:US
Practice Address - Phone:606-849-2323
Practice Address - Fax:606-849-2025
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009247363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100351200Medicaid
KYK128240Medicare PIN