1366526873 NPI number — MRS. STACY DANAE FITZGERALD LMT

Table of content: MRS. STACY DANAE FITZGERALD LMT (NPI 1366526873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366526873 NPI number — MRS. STACY DANAE FITZGERALD LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
STACY
Provider Middle Name:
DANAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILLASPIE
Provider Other First Name:
STACY
Provider Other Middle Name:
DANAE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366526873
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6412 LAKE SUZZANNE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32404-3407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-867-9254
Provider Business Mailing Address Fax Number:
850-481-0225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 AIRPORT RD
Provider Second Line Business Practice Location Address:
SUITE I
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-4030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-867-9254
Provider Business Practice Location Address Fax Number:
850-481-0225
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA48416 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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