Provider Demographics
NPI:1710939301
Name:HOPPER, STACYE LEIGH (APN)
Entity type:Individual
Prefix:
First Name:STACYE
Middle Name:LEIGH
Last Name:HOPPER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-422-0213
Mailing Address - Fax:
Practice Address - Street 1:619 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3903
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-882-5052
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT100792363LF0000X
TN6005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1710939301Medicaid