Provider Demographics
NPI:1336335603
Name:GEORGE, STACEY L (APN)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:L
Last Name:GEORGE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5197 PROVIDENCE CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-7838
Mailing Address - Country:US
Mailing Address - Phone:870-802-0686
Mailing Address - Fax:
Practice Address - Street 1:5197 PROVIDENCE CIR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-7838
Practice Address - Country:US
Practice Address - Phone:870-802-0686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165274758Medicaid