Provider Demographics
NPI:1912947169
Name:SMITH, STACEY L (FNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 MARY SHERMAN DR
Mailing Address - Street 2:PO BOX 230
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-7633
Mailing Address - Country:US
Mailing Address - Phone:812-268-3318
Mailing Address - Fax:812-268-4017
Practice Address - Street 1:2229 MARY SHERMAN DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7633
Practice Address - Country:US
Practice Address - Phone:812-268-3318
Practice Address - Fax:812-268-4017
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000086A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN153868Medicare Oscar/Certification