Provider Demographics
NPI:1750873089
Name:MICHELIN, STACEY (FNP-C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MICHELIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:BOOTHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2269 WILMA RUDOLPH BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-8416
Mailing Address - Country:US
Mailing Address - Phone:931-542-9010
Mailing Address - Fax:844-557-9010
Practice Address - Street 1:2269 WILMA RUDOLPH BLVD STE 106
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-8416
Practice Address - Country:US
Practice Address - Phone:931-542-9010
Practice Address - Fax:844-557-9010
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN83-1860610OtherIRS