Healthcare Provider Details

I. General information

NPI: 1154538247
Provider Name (Legal Business Name): STACI MARIE GRABER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 WILLOW CREEK DR. STE 203
SPRINGDALE AR
72762
US

IV. Provider business mailing address

5501 WILLOW CREEK DR. STE 203
SPRINGDALE AR
72762
US

V. Phone/Fax

Practice location:
  • Phone: 479-757-8001
  • Fax: 479-750-0571
Mailing address:
  • Phone: 479-575-9359
  • Fax: 479-575-9415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberA001929
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: