Provider Demographics
NPI:1104814805
Name:HODGES, STACEY S (ACNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:S
Last Name:HODGES
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11567
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308
Mailing Address - Country:US
Mailing Address - Phone:731-661-0086
Mailing Address - Fax:731-661-0281
Practice Address - Street 1:9 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-661-0086
Practice Address - Fax:731-661-0281
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN105802164W00000X, 363LA2100X
TNAPN 7203363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3902598Medicaid
MH0593346OtherDEA
3902591Medicare PIN
P27615Medicare UPIN