Provider Demographics
NPI:1932438751
Name:ETTINGER, STACY GAIL (CPNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:GAIL
Last Name:ETTINGER
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 1:3019 THOMAS AVE APT 1402
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2814
Mailing Address - Country:US
Mailing Address - Phone:214-456-3214
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:CENTER FOR CANCER AND BLOOD DISORDERS
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-3214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX696355363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics