Provider Demographics
NPI:1740340884
Name:BROMLEY, STACY R (PA-C)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:BROMLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-425-5752
Mailing Address - Fax:731-425-5783
Practice Address - Street 1:4039 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3483
Practice Address - Country:US
Practice Address - Phone:731-686-8995
Practice Address - Fax:731-686-8997
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95000550Medicaid
KYK053211Medicare PIN
KYK053212Medicare PIN
KYP01163707Medicare PIN