Basic Information
| Provider Information | |||||||||
| NPI: | 1982110813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUCKY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | GOMEZ | ||||||||
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| Credential: | MSN, WHNP-BC, IBCLC | ||||||||
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| OtherLastName: | STUCKY | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | SERRATA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22 COMMANDO AVE | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283071532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543388084 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1235 RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283014401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104333600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2017 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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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 | 363LW0102X | 5010112 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.