Healthcare Provider Details

I. General information

NPI: 1306481189
Provider Name (Legal Business Name): STACEY V EASON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10209 W CENTRAL AVE STE 1
WICHITA KS
67212-4685
US

IV. Provider business mailing address

10209 W CENTRAL AVE STE 1
WICHITA KS
67212-4685
US

V. Phone/Fax

Practice location:
  • Phone: 316-841-6861
  • Fax: 316-854-9673
Mailing address:
  • Phone: 316-841-6861
  • Fax: 316-854-9673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number53-80908
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number53-79073
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: