Basic Information
| Provider Information | |||||||||
| NPI: | 1497999155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | SUZETTE | ||||||||
| MiddleName: | CARROLL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RN APN FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 YORK COMMONS | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380636088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316351327 | ||||||||
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| Practice Location | |||||||||
| Address1: | 317 CLEVELAND ST | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380631205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312211804 | ||||||||
| FaxNumber: | 7312211880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2009 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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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 | 363LF0000X | APN0000013889 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 103I501930 | 01 | TN | MEDICARE PTAN | OTHER | 4319063 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 1526784 | 05 | TN | MEDICAID |