Provider Demographics
NPI:1528483591
Name:GREGORY, STACY LAINE (ACNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LAINE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13261 S HILLCREEK RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:TX
Mailing Address - Zip Code:75791-5215
Mailing Address - Country:US
Mailing Address - Phone:903-571-8545
Mailing Address - Fax:
Practice Address - Street 1:1809 CAPITAL DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8438
Practice Address - Country:US
Practice Address - Phone:903-509-4499
Practice Address - Fax:903-509-4490
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX601016363LA2100X
TXAP125238363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner