Provider Demographics
NPI:1992741342
Name:LACEY, STEPHANIE REGAN (DO)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:REGAN
Last Name:LACEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:841 PRUDENTIAL DR
Practice Address - Street 2:UFJP PEDIATRIC CARDIOLOGY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8329
Practice Address - Country:US
Practice Address - Phone:904-493-1610
Practice Address - Fax:904-493-2363
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9818208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2759861-00Medicaid
GA109704014AMedicaid
FL275986100Medicaid
U7900YMedicare PIN
FLU7900ZMedicare PIN
FL275986100Medicaid
FLP00800888Medicare PIN