Provider Demographics
NPI:1972618130
Name:DENVER, STACEY DALE (RN, FNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:DALE
Last Name:DENVER
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 W MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-0903
Mailing Address - Country:US
Mailing Address - Phone:210-358-5437
Mailing Address - Fax:210-358-9970
Practice Address - Street 1:903 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-0903
Practice Address - Country:US
Practice Address - Phone:210-358-5437
Practice Address - Fax:210-358-9970
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP111891363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX671870OtherMEDICARE FQHC
TX155231706Medicaid
TX155231702Medicaid
TX189890001Medicaid
TX8Y3568OtherBLUE CROSS BLUE SHIELD
TX155231707OtherCSHCN