Provider Demographics
NPI:1699424986
Name:BACON, STEPHANIE (APRN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:SERBAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3508 ROLLING TRL
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3534
Mailing Address - Country:US
Mailing Address - Phone:850-376-7678
Mailing Address - Fax:
Practice Address - Street 1:3508 ROLLING TRL
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3534
Practice Address - Country:US
Practice Address - Phone:850-376-7678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018258363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily