Provider Demographics
NPI:1043370323
Name:MERRITT BAKER, STACEY L (PNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:MERRITT BAKER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6923 COLBURN DR
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-6107
Mailing Address - Country:US
Mailing Address - Phone:571-730-0332
Mailing Address - Fax:
Practice Address - Street 1:6923 COLBURN DR
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-6107
Practice Address - Country:US
Practice Address - Phone:571-730-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1007058363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q63780Medicare UPIN