Provider Demographics
NPI:1992763569
Name:MARTIN, STACY D (CRNP)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP/ARNP
Mailing Address - Street 1:1566 PEA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-7702
Mailing Address - Country:US
Mailing Address - Phone:928-266-7022
Mailing Address - Fax:
Practice Address - Street 1:1566 PEA RIDGE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42164-7702
Practice Address - Country:US
Practice Address - Phone:928-266-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ134146363L00000X
AZRN134146363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P85091Medicare UPIN