Healthcare Provider Details

I. General information

NPI: 1134640725
Provider Name (Legal Business Name): STACY ALLYN BRUBAKER APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2017
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 REFUGEE RD FL 2
PICKERINGTON OH
43147-9861
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-8617
  • Fax:
Mailing address:
  • Phone: 614-293-8617
  • Fax: 614-685-5246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.19071
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number19071
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: