Provider Demographics
NPI:1619909009
Name:SMALLEY, STACY M (CNM MSN)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:M
Last Name:SMALLEY
Suffix:
Gender:F
Credentials:CNM MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 ROGERS AVE STE 403
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4034
Mailing Address - Country:US
Mailing Address - Phone:479-785-2229
Mailing Address - Fax:845-353-1987
Practice Address - Street 1:7001 ROGERS AVE STE 403
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4034
Practice Address - Country:US
Practice Address - Phone:479-785-2229
Practice Address - Fax:479-478-6745
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001316-1176B00000X
ARM002126176B00000X, 367A00000X
CTLNM000261367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
40LNM0261CT05OtherANTHEM BLUE CROSS
26100OtherCONNECTICARE
P3644739OtherTAX ID
060967790OtherOXFORD HEALTHPLAN UNITED
26100OtherCONNECTICARE