Healthcare Provider Details

I. General information

NPI: 1497284723
Provider Name (Legal Business Name): STACY MASTRO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 11/01/2025
Certification Date: 11/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 MORELAND AVE SE
ATLANTA GA
30316-1926
US

IV. Provider business mailing address

2429 MARTIN LUTHER KING JR DR SW # 4717
ATLANTA GA
30311-1713
US

V. Phone/Fax

Practice location:
  • Phone: 404-688-9300
  • Fax:
Mailing address:
  • Phone: 404-691-9580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN193501
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8445321-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8445321-4405
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: