Provider Demographics
NPI:1194371344
Name:WINTERS, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WINTERS
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:PO BOX 746871
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6871
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:
Practice Address - Street 1:5246 CHAMBERLAYNE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-2950
Practice Address - Country:US
Practice Address - Phone:804-913-7029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024187037363L00000X
MDR201184363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner