Basic Information
| Provider Information | |||||||||
| NPI: | 1396342895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAHL | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | REYNOLDS | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1732 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998331732 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 FRAM TREET | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998330589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077724291 | ||||||||
| FaxNumber: | 9077733085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 163327 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.