Healthcare Provider Details

I. General information

NPI: 1083388359
Provider Name (Legal Business Name): STACY LEE EDGAR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 KATY LN
POPLAR BLUFF MO
63901-2300
US

IV. Provider business mailing address

1961 COUNTY ROAD 607
POPLAR BLUFF MO
63901-5544
US

V. Phone/Fax

Practice location:
  • Phone: 573-712-2546
  • Fax:
Mailing address:
  • Phone: 573-300-9971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021026192
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: