Provider Demographics
NPI:1649508078
Name:KING, STACEY (CFNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 HOSPITAL DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4772
Mailing Address - Country:US
Mailing Address - Phone:505-982-3534
Mailing Address - Fax:
Practice Address - Street 1:1630 HOSPITAL DR
Practice Address - Street 2:SUITE D
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4772
Practice Address - Country:US
Practice Address - Phone:505-982-3534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily