Provider Demographics
NPI:1457066607
Name:MATHENY, STACEY LYNN (RN, BSN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:MATHENY
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8302 OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5137
Mailing Address - Country:US
Mailing Address - Phone:903-646-3239
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8369
Practice Address - Country:US
Practice Address - Phone:903-606-8718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1022832163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse