Provider Demographics
NPI:1023254257
Name:GATHRIGHT, STACI HERNDON (FNP)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:HERNDON
Last Name:GATHRIGHT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 RIFE MEDICAL LANE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1452
Mailing Address - Country:US
Mailing Address - Phone:479-338-5555
Mailing Address - Fax:479-338-5533
Practice Address - Street 1:2708 RIFE MEDICAL LANE
Practice Address - Street 2:SUITE 130
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758
Practice Address - Country:US
Practice Address - Phone:479-338-5555
Practice Address - Fax:479-338-5533
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003219363LF0000X
ARR66969363L00000X
ARATP-000187363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5V113Medicare PIN