Basic Information
| Provider Information | |||||||||
| NPI: | 1376093278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOGLE | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 523 S FANNIN AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035359041 | ||||||||
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| Practice Location | |||||||||
| Address1: | 214 E HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035931892 | ||||||||
| FaxNumber: | 9035331747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2016 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP132078 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.