Healthcare Provider Details

I. General information

NPI: 1477521466
Provider Name (Legal Business Name): PAMELA JEAN STACY LCSW, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N MARR RD
COLUMBUS IN
47201-6660
US

IV. Provider business mailing address

645 S ROGERS ST
BLOOMINGTON IN
47403-2353
US

V. Phone/Fax

Practice location:
  • Phone: 812-314-3400
  • Fax: 812-376-4875
Mailing address:
  • Phone: 812-339-1691
  • Fax: 812-337-2438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28142163A
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006033A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: