Provider Demographics
NPI:1366065104
Name:POOLE, STACEY ANN (DNP, RN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:POOLE
Suffix:
Gender:F
Credentials:DNP, RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 RISEN STAR DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-6071
Mailing Address - Country:US
Mailing Address - Phone:480-808-9505
Mailing Address - Fax:
Practice Address - Street 1:521 RISEN STAR DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-6071
Practice Address - Country:US
Practice Address - Phone:480-608-5157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9559718163W00000X
AZ245674363LP0808X
TXAP145602363LP0808X
FLAPRN11012113363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty