Provider Demographics
NPI:1649761180
Name:SALMONSON, STACEY ELAINE (APRN, CNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ELAINE
Last Name:SALMONSON
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 E EMPIRE ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-5402
Mailing Address - Country:US
Mailing Address - Phone:309-556-7800
Mailing Address - Fax:
Practice Address - Street 1:3024 E EMPIRE ST STE 2A
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-5402
Practice Address - Country:US
Practice Address - Phone:309-556-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2342234363LP0808X
COAPN.0994059363LP0808X
IL277003306363LP0808X
COC-APN.0001086-C-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health