Provider Demographics
NPI:1174514459
Name:BEASLEY, STACEY A (CNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-4658
Mailing Address - Fax:614-722-6746
Practice Address - Street 1:555 S 18TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2654
Practice Address - Country:US
Practice Address - Phone:614-722-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.07722363LP0200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNP07722OtherCNP NUMBER
OH3032006Medicaid
OHRN302896OtherRN LICENSE NUMBER