Provider Demographics
NPI:1861162414
Name:YOHANNAN, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:YOHANNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:GEORGEKUTTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 29650, DEPT# 880579
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038
Mailing Address - Country:US
Mailing Address - Phone:480-626-1746
Mailing Address - Fax:
Practice Address - Street 1:4725 WELLINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-4945
Practice Address - Country:US
Practice Address - Phone:469-320-1267
Practice Address - Fax:945-242-8020
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144895363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily