Provider Demographics
NPI:1013689363
Name:WHITE, STACEY RENAE (AGPCNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RENAE
Last Name:WHITE
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4042 CAMBRIAN CIR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-5023
Mailing Address - Country:US
Mailing Address - Phone:804-888-1198
Mailing Address - Fax:
Practice Address - Street 1:3001 HUNGARY SPRING RD STE C
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-2428
Practice Address - Country:US
Practice Address - Phone:804-415-7156
Practice Address - Fax:804-420-2854
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181325363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health