1831267756 NPI number — STACEY SNYDER PANNELL FNP

Table of content: STACEY SNYDER PANNELL FNP (NPI 1831267756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831267756 NPI number — STACEY SNYDER PANNELL FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANNELL
Provider First Name:
STACEY
Provider Middle Name:
SNYDER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
INGRAM
Provider Other First Name:
STACEY
Provider Other Middle Name:
SNYDER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1831267756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
422 BERKSHIRE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39157-3622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
901-227-8591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1668 WEST PEACE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-859-5213
Provider Business Practice Location Address Fax Number:
601-859-8771
Provider Enumeration Date:
11/30/2006

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:  R814593 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 3001825 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03309595 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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