Provider Demographics
NPI:1649814609
Name:REDDING, STACY LEANN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LEANN
Last Name:REDDING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:BOSWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:1102 14TH ST N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3662
Mailing Address - Country:US
Mailing Address - Phone:615-582-1346
Mailing Address - Fax:
Practice Address - Street 1:1800 ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1332
Practice Address - Country:US
Practice Address - Phone:615-582-1346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-03
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013404363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily