Basic Information
| Provider Information | |||||||||
| NPI: | 1215489356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN, AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 MAY ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761047639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177022450 | ||||||||
| FaxNumber: | 8177028445 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 N MAGDALEN ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769035400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256581511 | ||||||||
| FaxNumber: | 3254812166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2016 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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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 | 363LA2100X | AP132376 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 385085103 | 05 | TX | MEDICAID | 732170 | 01 | TX | MEDICARE | OTHER |