Healthcare Provider Details

I. General information

NPI: 1285806422
Provider Name (Legal Business Name): STACY GARDNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W SAINT LOUIS ST
WEST FRANKFORT IL
62896-1956
US

IV. Provider business mailing address

410 W SAINT LOUIS ST
WEST FRANKFORT IL
62896-1956
US

V. Phone/Fax

Practice location:
  • Phone: 618-932-2200
  • Fax: 618-932-2202
Mailing address:
  • Phone: 618-932-2200
  • Fax: 618-932-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number209007026
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STACY GARDNER
Title or Position: FAMILY NURSE PRACTITIONER/ OWNER
Credential: FNP-BC
Phone: 618-932-2200