Provider Demographics
NPI:1104059492
Name:BRUNQUIST, STACY LYNN (RNC ANP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:BRUNQUIST
Suffix:
Gender:F
Credentials:RNC ANP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:ROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:3200 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4615
Practice Address - Country:US
Practice Address - Phone:907-212-5006
Practice Address - Fax:907-212-4896
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1095363LN0005X
OR200950111NP NNP-PP363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1570883Medicaid