Provider Demographics
NPI:1063241438
Name:PEMBERTON, STACY M
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 SEQUATCHIE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SEQUATCHIE
Mailing Address - State:TN
Mailing Address - Zip Code:37374-5000
Mailing Address - Country:US
Mailing Address - Phone:423-605-7415
Mailing Address - Fax:
Practice Address - Street 1:298 SEQUATCHIE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SEQUATCHIE
Practice Address - State:TN
Practice Address - Zip Code:37374-5000
Practice Address - Country:US
Practice Address - Phone:423-605-7415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36877363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health