Healthcare Provider Details

I. General information

NPI: 1104814805
Provider Name (Legal Business Name): STACEY S HODGES ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 PHYSICIANS DR
JACKSON TN
38305
US

IV. Provider business mailing address

PO BOX 11567
JACKSON TN
38308
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-0086
  • Fax: 731-661-0281
Mailing address:
  • Phone: 731-661-0086
  • Fax: 731-661-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN105802
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN 7203
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberRN105802
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: