Provider Demographics
NPI:1538412176
Name:MCKEAN, STACI MICHELLE (ACNS)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:MICHELLE
Last Name:MCKEAN
Suffix:
Gender:F
Credentials:ACNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 WORTH ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3410 WORTH ST
Practice Address - Street 2:SUITE 250
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2003
Practice Address - Country:US
Practice Address - Phone:214-820-6856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX700711364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX700711OtherRN LICENSE
TXAP122596OtherAPRN LICENSE NUMBER
TX13218OtherRX AUTHORIZATION
TX90194305OtherDPS
MM2793479OtherDEA