Basic Information
| Provider Information | |||||||||
| NPI: | 1528560844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROWNOVER | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1136 HUMMINGBIRD LN | ||||||||
| Address2: | |||||||||
| City: | GLEN ROSE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760436910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326315933 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177023636 | ||||||||
| FaxNumber: | 8179278769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2018 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP135935 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.