MEDICARE: MRS. STACIE LYNNE EBERSOLD MSN, NP-C

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	APRN11041685	FL
2	363LF0000X	Family Nurse Practitioner	SP020581	PA
3	363LF0000X	Family Nurse Practitioner	41288	TN

General Provider Information

NPI Number	:	1750943155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACIE LYNNE EBERSOLD MSN, NP-C

Provider Business Mailing Address
First Line	:	PO BOX 211699
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55121-3699
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 S JUNIPER ST FL 3
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-1316
Country	:	US
Telephone Number	:	866-849-0692
Fax Number	:

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

Provider Enumeration Date	:	07/05/2019
Last Update Date	:	05/11/2026

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