Healthcare Provider Details

I. General information

NPI: 1255981528
Provider Name (Legal Business Name): STACY R MARRIOTT APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY R AUSMUS FNP-BC

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT ANTHONYS WAY STE 205
ALTON IL
62002-4569
US

IV. Provider business mailing address

2 SAINT ANTHONYS WAY STE 205
ALTON IL
62002-4569
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-2222
  • Fax: 618-463-5004
Mailing address:
  • Phone: 618-463-2222
  • Fax: 618-463-5004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277002128
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: