Healthcare Provider Details

I. General information

NPI: 1487005724
Provider Name (Legal Business Name): STACEY FAGUE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY DIEHL

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 WALNUT BOTTOM RD
SHIPPENSBURG PA
17257-8219
US

IV. Provider business mailing address

601 MEMORY LN
YORK PA
17402-2231
US

V. Phone/Fax

Practice location:
  • Phone: 717-477-2764
  • Fax:
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-851-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP016266
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: