Provider Demographics
NPI:1194252601
Name:HAMMOUD, STACIE LEE (APRN)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:LEE
Last Name:HAMMOUD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LEE
Other - Last Name:COBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-1771
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9285590363LA2100X, 363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIZ363ZOtherMEDICARE
FL20990000Medicaid