Provider Demographics
NPI:1447684923
Name:WARD, STACEY L (APRN)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:WARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:WARD-HAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19654
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9654
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-1229
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 0300
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-1229
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-012973364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILF400280425Medicare PIN