Provider Demographics
NPI:1750348272
Name:STACY, CYNTHIA D (FNPC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:D
Last Name:STACY
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 SIXTH BAXTER CROSSING
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708
Mailing Address - Country:US
Mailing Address - Phone:803-396-8100
Mailing Address - Fax:803-396-8040
Practice Address - Street 1:502 SIXTH BAXTER CROSSING
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-396-8100
Practice Address - Fax:803-396-8040
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN 2740363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0940Medicaid
AA12837366Medicare PIN
Q66898Medicare UPIN
AA12837180Medicare PIN