Provider Demographics
NPI:1912087214
Name:BROWN, STACEY MARIE (PAC)
Entity type:Individual
Prefix:PROF
First Name:STACEY
Middle Name:MARIE
Last Name:BROWN
Suffix:
Gender:F
Credentials:PAC
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 1290
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0022
Mailing Address - Country:US
Mailing Address - Phone:334-567-6579
Mailing Address - Fax:334-567-5393
Practice Address - Street 1:73888 TALLASSEE HWY
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-7308
Practice Address - Country:US
Practice Address - Phone:334-567-6579
Practice Address - Fax:334-567-5393
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA252363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP59199Medicare UPIN