1972618130 NPI number — STACEY DALE DENVER RN, FNP

Table of content: (NPI 1295547248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972618130 NPI number — STACEY DALE DENVER RN, FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENVER
Provider First Name:
STACEY
Provider Middle Name:
DALE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972618130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
903 W MARTIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78207-0903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-358-5437
Provider Business Mailing Address Fax Number:
210-358-9970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 W MARTIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78207-0903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-358-5437
Provider Business Practice Location Address Fax Number:
210-358-9970
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP111891 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 671870 . This is a "MEDICARE FQHC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 155231706 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 155231702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 189890001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8Y3568 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 155231707 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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