Provider Demographics
NPI:1730719311
Name:GREEN, STACIE LEIGH (APRN)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:LEIGH
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LEIGH
Other - Last Name:SAGESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 SUN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1609
Mailing Address - Country:US
Mailing Address - Phone:606-438-5445
Mailing Address - Fax:
Practice Address - Street 1:125 S MAIN CROSS ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1065
Practice Address - Country:US
Practice Address - Phone:606-638-0938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014209363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health