Healthcare Provider Details

I. General information

NPI: 1386365542
Provider Name (Legal Business Name): STACY STATS CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

IV. Provider business mailing address

15001 PANSY CT
WOODBRIDGE VA
22193-3385
US

V. Phone/Fax

Practice location:
  • Phone: 760-637-7813
  • Fax:
Mailing address:
  • Phone: 760-637-7813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License Number4515
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: