Provider Demographics
NPI:1265705743
Name:ELDRIDGE, STACY (FNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E PALMER RD
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2281
Mailing Address - Country:US
Mailing Address - Phone:937-592-4015
Mailing Address - Fax:
Practice Address - Street 1:1134 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2379
Practice Address - Country:US
Practice Address - Phone:937-651-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003974A363LF0000X
IN28137260A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000772667OtherANTHEM FAM MED PIN UNDER TIN 35-2030653
IN201072520Medicaid
IN000001037727OtherEMERGENCY MED PIN UNDER TIN 35-2030653
IN201072520Medicaid
INM400072550Medicare PIN