Provider Demographics
NPI:1912910142
Name:STROUD, STACEY A (PA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:STROUD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1852
Mailing Address - Country:US
Mailing Address - Phone:629-255-3486
Mailing Address - Fax:
Practice Address - Street 1:325 OLD PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-4493
Practice Address - Country:US
Practice Address - Phone:629-255-2075
Practice Address - Fax:629-255-4164
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ012341Medicaid
TNQ012341Medicaid
TN103I977061Medicare PIN
TN3381621Medicaid
TNQ012341Medicaid