Healthcare Provider Details

I. General information

NPI: 1699076547
Provider Name (Legal Business Name): STACY L JUSTICE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 MAIN ST
LOGAN WV
25601-3809
US

IV. Provider business mailing address

PO BOX 390
HUNTINGTON WV
25708-0390
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-3435
  • Fax:
Mailing address:
  • Phone: 304-429-1088
  • Fax: 304-696-1623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number62349
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62349
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: