Basic Information
| Provider Information | |||||||||
| NPI: | 1487159943 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURLEYSON | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 HAWTHORN RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628811028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185484545 | ||||||||
| FaxNumber: | 6185484577 | ||||||||
| Practice Location | |||||||||
| Address1: | 1275 HAWTHORN RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628811028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185484545 | ||||||||
| FaxNumber: | 6185484577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2018 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F03180485 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | 209017646 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.