Provider Demographics
NPI:1962123620
Name:STITZ, STACEY JUNG (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:JUNG
Last Name:STITZ
Suffix:
Gender:F
Credentials:PMHNP-BC
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 544
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-0544
Mailing Address - Country:US
Mailing Address - Phone:219-863-7040
Mailing Address - Fax:
Practice Address - Street 1:707 MOON ROAD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168
Practice Address - Country:US
Practice Address - Phone:317-839-7737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28192473A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71012947AOtherAPRN PRESCRIPTIVE AUTHORITY