Healthcare Provider Details

I. General information

NPI: 1851957948
Provider Name (Legal Business Name): STACIE MARIE RICKLEY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 NEW GERMANY RD
SUMMERHILL PA
15958-5301
US

IV. Provider business mailing address

1020 FRANKLIN STREET
JOHNSTOWN PA
15905-4109
US

V. Phone/Fax

Practice location:
  • Phone: 814-244-2939
  • Fax:
Mailing address:
  • Phone: 814-534-9230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberRN547989
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberMW010546
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: