Healthcare Provider Details

I. General information

NPI: 1225324668
Provider Name (Legal Business Name): STACEY LYNNE HASTREITER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BURMA AVE
GILLETTE WY
82716-3426
US

IV. Provider business mailing address

501 S BURMA AVE
GILLETTE WY
82716-3426
US

V. Phone/Fax

Practice location:
  • Phone: 307-688-1415
  • Fax: 307-688-1420
Mailing address:
  • Phone: 307-688-1415
  • Fax: 307-688-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number29229.1108
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: