Provider Demographics
NPI:1689452732
Name:SUMNER, STACY LYNN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:SUMNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:KUHLMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:489 TRAMMEL RD
Mailing Address - Street 2:
Mailing Address - City:CARRIER MILLS
Mailing Address - State:IL
Mailing Address - Zip Code:62917-1156
Mailing Address - Country:US
Mailing Address - Phone:618-499-1405
Mailing Address - Fax:
Practice Address - Street 1:489 TRAMMEL RD
Practice Address - Street 2:
Practice Address - City:CARRIER MILLS
Practice Address - State:IL
Practice Address - Zip Code:62917-1156
Practice Address - Country:US
Practice Address - Phone:618-499-1405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174H000000172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker