Provider Demographics
NPI:1104461334
Name:SCOTT, STACY ANN (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:SCOTT
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13300 ATLANTIC BLVD APT 123
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6128
Mailing Address - Country:US
Mailing Address - Phone:904-896-6201
Mailing Address - Fax:
Practice Address - Street 1:13300 ATLANTIC BLVD APT 123
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6128
Practice Address - Country:US
Practice Address - Phone:904-896-6201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9360429163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS356-781-66-866-0Medicaid