Provider Demographics
NPI:1528480035
Name:PACE, STACIE (AGACNP, AGPCNP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:PACE
Suffix:
Gender:F
Credentials:AGACNP, AGPCNP
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2910 MAGNOLIA PL
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-2428
Mailing Address - Country:US
Mailing Address - Phone:601-466-9495
Mailing Address - Fax:601-466-9495
Practice Address - Street 1:709 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3666
Practice Address - Country:US
Practice Address - Phone:601-466-9495
Practice Address - Fax:601-469-9965
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0100762-C-NP363L00000X
AZRNP232597363L00000X
MS879432363LA2100X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05656575Medicaid