Provider Demographics
NPI:1215056718
Name:STACKHOUSE, PHYLLIS C (CRNP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:C
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 ROLLING RIDGE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7639
Mailing Address - Country:US
Mailing Address - Phone:814-689-4980
Mailing Address - Fax:814-689-4990
Practice Address - Street 1:476 ROLLING RIDGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7639
Practice Address - Country:US
Practice Address - Phone:814-689-4980
Practice Address - Fax:814-689-4990
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN-204012-L163W00000X
PASP-001330-D363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103171579Medicaid