Provider Demographics
NPI:1861853301
Name:WHITAKER, STACIA L (NP)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:L
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:L
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RR 208
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-4715
Practice Address - Fax:317-274-2065
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006146363LN0000X
IN28171919363LN0000X
IN71006146A363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal