Provider Demographics
NPI:1699234393
Name:WILLIAMS, STACEY LYN (CPNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 GYPSY LN W
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-1404
Mailing Address - Country:US
Mailing Address - Phone:443-243-6267
Mailing Address - Fax:
Practice Address - Street 1:1122 GYPSY LN W
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-1404
Practice Address - Country:US
Practice Address - Phone:443-243-6267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR119208363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics