Healthcare Provider Details

I. General information

NPI: 1265705743
Provider Name (Legal Business Name): STACY ELDRIDGE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 08/24/2024
Certification Date: 08/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 N MAIN ST
BELLEFONTAINE OH
43311-2379
US

IV. Provider business mailing address

205 E PALMER RD
BELLEFONTAINE OH
43311-2281
US

V. Phone/Fax

Practice location:
  • Phone: 937-651-6820
  • Fax:
Mailing address:
  • Phone: 937-592-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71003974A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28137260A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: