Provider Demographics
NPI:1235629171
Name:LAND, STACEY MARIE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:LAND
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 WILLOWBROOK DR SE
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-1410
Mailing Address - Country:US
Mailing Address - Phone:706-264-6751
Mailing Address - Fax:
Practice Address - Street 1:251 HIGHWAY 53 E
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-3026
Practice Address - Country:US
Practice Address - Phone:706-625-4410
Practice Address - Fax:706-629-2696
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN190644363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner