Basic Information
Provider Information | |||||||||
NPI: | 1932444809 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STACY | ||||||||
FirstName: | WHITNEY | ||||||||
MiddleName: | DONANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 204 E 1ST ST | ||||||||
Address2: |   | ||||||||
City: | ALICE | ||||||||
State: | TX | ||||||||
PostalCode: | 783324822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3616640145 | ||||||||
FaxNumber: | 3616642248 | ||||||||
Practice Location | |||||||||
Address1: | 115 W. MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BENAVIDES | ||||||||
State: | TX | ||||||||
PostalCode: | 78341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3612563663 | ||||||||
FaxNumber: | 3612563989 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2012 | ||||||||
LastUpdateDate: | 08/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 754455 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 312415801 | 05 | TX |   | MEDICAID |