=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710728837
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACIE L EDWARDS APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 10/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 E. HOSPITAL STREET
-----------------------------------------------------
City | SAN AUGUSTINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-275-9716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2132 S 1ST ST
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75901-5902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1165337
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------