Provider Demographics
NPI:1649872425
Name:ALLPORT-PRIDEMORE, STACY DAWN (FNP BC)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:DAWN
Last Name:ALLPORT-PRIDEMORE
Suffix:
Gender:F
Credentials:FNP BC
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:DAWN
Other - Last Name:ALLPORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:332 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1246
Mailing Address - Country:US
Mailing Address - Phone:304-343-1950
Mailing Address - Fax:866-225-4179
Practice Address - Street 1:332 6TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1246
Practice Address - Country:US
Practice Address - Phone:304-343-1950
Practice Address - Fax:866-225-4179
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV107640363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner