Provider Demographics
NPI:1912924663
Name:KUCHARCZK, STACY (CPNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KUCHARCZK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 CITY CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-8960
Mailing Address - Country:US
Mailing Address - Phone:252-338-2155
Mailing Address - Fax:252-338-7704
Practice Address - Street 1:1735 CITY CENTER BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-8960
Practice Address - Country:US
Practice Address - Phone:252-338-2155
Practice Address - Fax:252-338-7704
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004933363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA28859NOtherOPTIMA, OFC,FAMIS
VA7787758Medicaid
NC541778786OtherNC HEALTH CH