Basic Information
| Provider Information | |||||||||
| NPI: | 1538593470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WRIGHT | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 955860 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631953056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364985944 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 GOOD SAMARITAN WAY | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188991264 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2013 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209010682 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209010682 | 01 | IL | STATE LICENSE | OTHER |