Provider Demographics
NPI:1699059535
Name:STANDRIDGE, STACEY PENICK (NP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:PENICK
Last Name:STANDRIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:ELIZABETH
Other - Last Name:PENICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:1000 OCHSNER BLVD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-871-0095
Practice Address - Fax:985-871-0529
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA105551-6626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2175718Medicaid
MS00172269Medicaid
LA2175718Medicaid