Provider Demographics
NPI:1699089862
Name:TATE, STACIA KEYUNIA (FNP)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:KEYUNIA
Last Name:TATE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9332 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3108
Practice Address - Country:US
Practice Address - Phone:704-587-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004759363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006374Medicaid
SCNP2166Medicaid
NC1699089862Medicaid
NCNCB501DMedicare PIN
NC7006374Medicaid
NCNCB501CMedicare PIN
NCNCB501LMedicare PIN
NCNCB501MMedicare PIN
NCNCB501IMedicare PIN
NC1699089862Medicaid
NCNCB501EMedicare PIN
NCNCB501FMedicare PIN
NCNCB501HMedicare PIN
NCNCB501GMedicare PIN
NCNCB501AMedicare PIN