Provider Demographics
NPI:1912383043
Name:FIFER, STACY (APRN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:FIFER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 GRUMMAN PL STE B
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7927
Mailing Address - Country:US
Mailing Address - Phone:321-269-4240
Mailing Address - Fax:321-269-5248
Practice Address - Street 1:1250 GRUMMAN PL STE B
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7927
Practice Address - Country:US
Practice Address - Phone:321-269-4240
Practice Address - Fax:321-269-5248
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9309754207RH0002X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MH827OtherMEDICARE
FL102525700Medicaid