Provider Demographics
NPI:1619241007
Name:BEAVER, STACIE MICHELLE (CRNP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:MICHELLE
Last Name:BEAVER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-851-6969
Practice Address - Street 1:601 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:PA
Practice Address - Zip Code:17268-2332
Practice Address - Country:US
Practice Address - Phone:717-765-5088
Practice Address - Fax:717-765-5066
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR139236363LA2200X
PASP022183363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103802293Medicaid
12667440OtherCAQH
1619241007OtherNPI