Provider Demographics
NPI:1669995155
Name:TAYLOR, STACY LEE (RN)
Entity type:Individual
Prefix:MR
First Name:STACY
Middle Name:LEE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 FOX DR
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2102
Mailing Address - Country:US
Mailing Address - Phone:573-300-8115
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1573
Practice Address - Country:US
Practice Address - Phone:573-776-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011021213163WG0000X, 163WM0705X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical