Basic Information
| Provider Information | |||||||||
| NPI: | 1548528086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMSON | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893629411 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 805 W CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | STANDISH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898464888 | ||||||||
| FaxNumber: | 9898463538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2012 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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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 | 69512 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | RN.369896 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | COA.13045-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3810028149 | 05 | WV | MEDICAID | 0112055 | 05 | OH | MEDICAID |