Healthcare Provider Details

I. General information

NPI: 1245021120
Provider Name (Legal Business Name): STACIE G CARLOCK DNP, APRN, NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E DAWSON ST
TYLER TX
75701-2036
US

IV. Provider business mailing address

3213 SUNSET DR
SAN ANGELO TX
76904-6042
US

V. Phone/Fax

Practice location:
  • Phone: 36-061-7219
  • Fax:
Mailing address:
  • Phone: 575-200-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number1205776
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: