Provider Demographics
NPI:1124455118
Name:DICK, STACYE (GNP-BC)
Entity type:Individual
Prefix:
First Name:STACYE
Middle Name:
Last Name:DICK
Suffix:
Gender:F
Credentials:GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14121 PARKE LONG CT
Mailing Address - Street 2:SUITE 200 & 201
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1647
Mailing Address - Country:US
Mailing Address - Phone:571-449-3585
Mailing Address - Fax:800-752-2471
Practice Address - Street 1:14121 PARKE LONG CT
Practice Address - Street 2:SUITE 200 & 201
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1647
Practice Address - Country:US
Practice Address - Phone:571-449-3585
Practice Address - Fax:800-752-2471
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX256896363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology