Healthcare Provider Details

I. General information

NPI: 1407564271
Provider Name (Legal Business Name): STACEY JAMES CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9901 MEDICAL CENTER DR
ROCKVILLE MD
20850-3357
US

IV. Provider business mailing address

9901 MEDICAL CENTER DR
ROCKVILLE MD
20850-3357
US

V. Phone/Fax

Practice location:
  • Phone: 111-111-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR253747
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR253747
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: