Provider Demographics
NPI:1174920029
Name:CARTER, STACY MARCUM (APRN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARCUM
Last Name:CARTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:KCH 4TH FLOOR, SUITE C400
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-7001
Mailing Address - Country:US
Mailing Address - Phone:859-323-8651
Mailing Address - Fax:859-323-8641
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:KCH 4TH FLOOR, SUITE C400
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-7001
Practice Address - Country:US
Practice Address - Phone:859-323-8651
Practice Address - Fax:859-323-8641
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014034200363LP0200X
KY3009510363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201318580Medicaid
KY7100368710Medicaid
KYK177520Medicare PIN