Basic Information
| Provider Information | |||||||||
| NPI: | 1104215854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAWBUSH | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4046 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658084046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172695712 | ||||||||
| FaxNumber: | 4172697567 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172699812 | ||||||||
| FaxNumber: | 4172699853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2015 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2014044284 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1104215854 | 05 | MO | MEDICAID |