Provider Demographics
NPI:1902469075
Name:WILSON, STACIE MICHELLE (ANP)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD STE 6017B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8274
Mailing Address - Country:US
Mailing Address - Phone:314-251-7840
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 6017B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8274
Practice Address - Country:US
Practice Address - Phone:314-251-7840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019006496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine