Provider Demographics
NPI:1457043077
Name:STACY, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-205-4750
Mailing Address - Fax:517-205-5968
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4750
Practice Address - Fax:517-205-5968
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704346507363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care