Provider Demographics
NPI:1275215006
Name:MENOS, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MENOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:321-221-9454
Practice Address - Street 1:225 E 7TH ST
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-5327
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-886-4282
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030279363A00000X
FLPA9119425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant