Healthcare Provider Details

I. General information

NPI: 1184738593
Provider Name (Legal Business Name): STACEY LYNN SMALLWOOD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY LYNN PHILLIPS APRN

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 OLD ROSEBUD RD STE 250
LEXINGTON KY
40509-8625
US

IV. Provider business mailing address

2700 OLD ROSEBUD RD STE 250
LEXINGTON KY
40509-8625
US

V. Phone/Fax

Practice location:
  • Phone: 859-264-1141
  • Fax: 859-264-1963
Mailing address:
  • Phone: 859-264-1141
  • Fax: 859-264-1963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3004185
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3004185
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: