Provider Demographics
NPI:1285806422
Name:STACY GARDNER
Entity type:Organization
Organization Name:STACY GARDNER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:618-932-2200
Mailing Address - Street 1:410 W SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-1956
Mailing Address - Country:US
Mailing Address - Phone:618-932-2200
Mailing Address - Fax:618-932-2202
Practice Address - Street 1:410 W SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-1956
Practice Address - Country:US
Practice Address - Phone:618-932-2200
Practice Address - Fax:618-932-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007026261QR1300X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health