Provider Demographics
NPI:1912775875
Name:CHALLE, STACEY LYNN (AGNP-C)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LYNN
Last Name:CHALLE
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S MAPLE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1753
Mailing Address - Country:US
Mailing Address - Phone:952-442-6006
Mailing Address - Fax:
Practice Address - Street 1:560 S MAPLE ST STE 100
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1753
Practice Address - Country:US
Practice Address - Phone:952-442-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11118363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology