Provider Demographics
NPI:1487159943
Name:BURLEYSON, STACI LYNN (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:LYNN
Last Name:BURLEYSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 HAWTHORN RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1028
Mailing Address - Country:US
Mailing Address - Phone:618-548-4545
Mailing Address - Fax:618-548-4577
Practice Address - Street 1:1275 HAWTHORN RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1028
Practice Address - Country:US
Practice Address - Phone:618-548-4545
Practice Address - Fax:618-548-4577
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILF03180485207Q00000X
IL209017646363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine