Provider Demographics
NPI:1831267756
Name:PANNELL, STACEY SNYDER (FNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:SNYDER
Last Name:PANNELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:SNYDER
Other - Last Name:INGRAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:422 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1668 WEST PEACE STREET
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046
Practice Address - Country:US
Practice Address - Phone:601-859-5213
Practice Address - Fax:601-859-8771
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR814593363LF0000X
AL3001825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03309595Medicaid