=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356956015
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY LEE MEYER APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2020
-----------------------------------------------------
Last Update Date | 11/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 CIVIC CENTER LN
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-855-8185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 OAK RIDGE DR
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53073-4039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-207-8415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 10141-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------