MEDICARE: MRS. STACEY LYNN SMALLWOOD APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	3004185	KY
2	363LF0000X	Family Nurse Practitioner	3004185	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184738593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACEY LYNN SMALLWOOD APRN

Provider Business Mailing Address
First Line	:	2700 OLD ROSEBUD RD STE 250
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-8625
Country	:	US
Telephone Number	:	859-264-1141
Fax Number	:	859-264-1963

Provider Business Practice Location Address
First Line	:	2700 OLD ROSEBUD RD STE 250
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-8625
Country	:	US
Telephone Number	:	859-264-1141
Fax Number	:	859-264-1963

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	07/22/2024

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