MEDICARE: STACEY NICOLE RUTLEDGE

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	367500000X	Certified Registered Nurse Anesthetist	2026014054	MO

General Provider Information

NPI Number	:	1548130669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY NICOLE RUTLEDGE

Provider Business Mailing Address
First Line	:	6027 KENSINGTON WAY
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-2369
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 W LIBERTY ST
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1921
Country	:	US
Telephone Number	:	573-756-6451
Fax Number	:

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

Provider Enumeration Date	:	11/05/2025
Last Update Date	:	03/30/2026

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Directions to “ STACEY NICOLE RUTLEDGE ” Practice Location

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