Basic Information
| Provider Information | |||||||||
| NPI: | 1821367327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STACY | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8288 S BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757035262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036067060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2011 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP121213 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | AP121213 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 729458 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LF0000X | AP121213 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-118 | 01 | TX | TRICARE | OTHER | 293825001 | 05 | TX | MEDICAID | 75-2616977-007 | 01 | TX | TRICARE | OTHER | 867N10 | 01 | TX | BCBS | OTHER | 75-2616977-066 | 01 | TX | TRICARE | OTHER | 752616977042 | 01 | TX | TRICARE | OTHER |