Provider Demographics
NPI:1538833736
Name:BRUEY, STACY ANNE (AG-ACNP BC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANNE
Last Name:BRUEY
Suffix:
Gender:F
Credentials:AG-ACNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 CLINCH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2435
Mailing Address - Country:US
Mailing Address - Phone:865-331-9075
Mailing Address - Fax:
Practice Address - Street 1:1819 CLINCH AVE STE 110
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2435
Practice Address - Country:US
Practice Address - Phone:865-331-9075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN446844163W00000X
OHAPRN.CNP.0029359363LA2100X
TN32326363LA2100X
TN265588163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ078565Medicaid