Provider Demographics
NPI:1154538247
Name:GRABER, STACI MARIE (APN)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:MARIE
Last Name:GRABER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 WILLOW CREEK DR. STE 203
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762
Mailing Address - Country:US
Mailing Address - Phone:479-575-9359
Mailing Address - Fax:479-575-9415
Practice Address - Street 1:5203 WILLOW CREEK DR. STE 203
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762
Practice Address - Country:US
Practice Address - Phone:479-757-8001
Practice Address - Fax:479-750-0571
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA001929363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167760758Medicaid