Provider Demographics
NPI:1386243871
Name:WIDEMAN, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WIDEMAN
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 1:3235 SATELLITE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8688
Mailing Address - Country:US
Mailing Address - Phone:360-643-6562
Mailing Address - Fax:619-415-8449
Practice Address - Street 1:8450 NW 102ND AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4750
Practice Address - Country:US
Practice Address - Phone:360-643-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-RXN.0001379363LP0808X
WAAPRN61166084-NP363LP0808X
GARN225736363LP0808X
OR202104630NP-PP363LP0808X
CA9501782363LP0808X
TX1071418363LP0808X
IAG168450363LP0808X
FLAPRN11012260363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health