Provider Demographics
NPI:1528098712
Name:CLARK, STACEY ELLEN (NP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ELLEN
Other - Last Name:BURGIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:53507 BICKETT
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-8570
Mailing Address - Country:US
Mailing Address - Phone:919-560-7925
Mailing Address - Fax:
Practice Address - Street 1:414 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3720
Practice Address - Country:US
Practice Address - Phone:919-560-7925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14812363L00000X
NC5005457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner