Provider Demographics
NPI:1154763514
Name:FARRELL, STACEY (CNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-4314
Mailing Address - Country:US
Mailing Address - Phone:662-455-4434
Mailing Address - Fax:662-455-4435
Practice Address - Street 1:411 FULTON ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4314
Practice Address - Country:US
Practice Address - Phone:662-455-4434
Practice Address - Fax:662-455-4435
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855653363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily