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General NPI Number Information
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NPI Number | 1689658031
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Entity Type | Individual
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Provider Name | STACY RUTH ROSE CRNP
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Gender | Female
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Dates
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Enumeration Date | 11/30/2005
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Last Update Date | 03/03/2021
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Provider Practice Location Address
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Address Line | 4176 STATE ROUTE 306
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City | WILLOUGHBY
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State | OH
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Zip | 44094-9203
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Country | US
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Telephone | 440-918-4630
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Fax | 440-918-4620
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Provider Business Mailing Address
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Address Line | 7590 AUBURN ROAD, SUITE 014 ATTN: MED STAFF
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City | CONCORD TWP
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State | OH
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Zip | 44077-9176
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Country | US
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Telephone | 440-354-1899
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Fax | 440-354-1845
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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 | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | COA.06089-NP
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License Number State | OH
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