Basic Information
| Provider Information | |||||||||
| NPI: | 1851957948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKLEY | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 FRANKLIN STREET | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145349230 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1265 NEW GERMANY RD | ||||||||
| Address2: | |||||||||
| City: | SUMMERHILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159585301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142442939 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2019 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | RN547989 | PA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 367A00000X | MW010546 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | N/A | OTHER |