Basic Information
| Provider Information | |||||||||
| NPI: | 1689229080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUCK | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | CPNP-PC, ARNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1139 130TH ST | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506669652 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 312 9TH ST SW | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506772929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193524120 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2019 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | C155255 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.