Provider Demographics
NPI:1750623500
Name:YANTIS, STACEY S (CRNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:S
Last Name:YANTIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:412 CREAMERY WAY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2551
Mailing Address - Country:US
Mailing Address - Phone:610-594-7590
Mailing Address - Fax:610-594-7597
Practice Address - Street 1:142 WALLACE AVE STE 201
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335
Practice Address - Country:US
Practice Address - Phone:610-873-2700
Practice Address - Fax:610-594-2625
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP012788363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031801480001Medicaid