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General NPI Number Information
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NPI Number | 1073076832
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Entity Type | Individual
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Provider Name | SEAN BRADLEY STACEY CRNA
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Gender | Male
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Dates
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Enumeration Date | 04/09/2019
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Last Update Date | 01/27/2023
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Provider Practice Location Address
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Address Line | 6420 CLAYTON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63117-1811
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Country | US
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Telephone | 314-768-8442
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Fax |
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Provider Business Mailing Address
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Address Line | 775A CHAMBERLAIN PL
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City | WEBSTER GROVES
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State | MO
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Zip | 63119-2707
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Country | US
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Telephone | 618-218-7267
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 209023764
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 123790
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License Number State | MO
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