Basic Information
| Provider Information | |||||||||
| NPI: | 1861425258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRESSY | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 COMMONWEALTH AVE SW | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300643750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707269029 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DR | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709417717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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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 | 163W00000X | RN139554 | GA | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 857886828B | 05 | GA | MEDICAID | 50BBKRT | 01 | GA | MEDICARE | OTHER |