Provider Demographics
NPI:1255981528
Name:MARRIOTT, STACY R (APRN, CNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:MARRIOTT
Suffix:
Gender:
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:R
Other - Last Name:AUSMUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:2 SAINT ANTHONYS WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4569
Mailing Address - Country:US
Mailing Address - Phone:618-463-2222
Mailing Address - Fax:618-463-5004
Practice Address - Street 1:2 SAINT ANTHONYS WAY STE 205
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4569
Practice Address - Country:US
Practice Address - Phone:618-463-2222
Practice Address - Fax:618-463-5004
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002128363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209019083OtherLICENSE