Healthcare Provider Details

I. General information

NPI: 1679194351
Provider Name (Legal Business Name): STACEY RENEE WARDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34617 AL HIGHWAY 75
FYFFE AL
35971-3488
US

IV. Provider business mailing address

1500 1ST AVE N UNIT 3
BIRMINGHAM AL
35203-1866
US

V. Phone/Fax

Practice location:
  • Phone: 256-623-5242
  • Fax: 256-623-5243
Mailing address:
  • Phone: 205-644-8256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-102742
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: