MEDICARE: STACY LEIGH SEDERWALL FNP

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	363LF0000X	Family Nurse Practitioner	2015001255	MO

General Provider Information

NPI Number	:	1255720876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY LEIGH SEDERWALL FNP

Provider Business Mailing Address
First Line	:	2840 BAGNELL DAM BLVD
Second Line	:
City	:	LAKE OZARK
State	:	MO
Zip	:	65049-9732
Country	:	US
Telephone Number	:	573-480-8888
Fax Number	:	502-399-8745

Provider Business Practice Location Address
First Line	:	2840 BAGNELL DAM BLVD
Second Line	:
City	:	LAKE OZARK
State	:	MO
Zip	:	65049-9732
Country	:	US
Telephone Number	:	573-480-8888
Fax Number	:	502-399-8745

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

Provider Enumeration Date	:	01/20/2015
Last Update Date	:	11/26/2025

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