Basic Information
| Provider Information | |||||||||
| NPI: | 1104814805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HODGES | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11567 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316610086 | ||||||||
| FaxNumber: | 7316610281 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 PHYSICIANS DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316610086 | ||||||||
| FaxNumber: | 7316610281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 10/12/2011 | ||||||||
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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 | 164W00000X | RN105802 | TN | N | Nursing Service Providers | Licensed Practical Nurse | 363LA2100X | RN105802 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | APN 7203 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 3902598 | 05 | TN | MEDICAID | MH0593346 | 01 | DEA | OTHER |