Provider Demographics
NPI:1043654726
Name:LACIOS, MARY STEPHANIE (AP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:STEPHANIE
Last Name:LACIOS
Suffix:
Gender:F
Credentials:AP
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 38
Mailing Address - Street 2:
Mailing Address - City:ANNA MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34216-0038
Mailing Address - Country:US
Mailing Address - Phone:941-779-8952
Mailing Address - Fax:
Practice Address - Street 1:5717 DEREK AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2413
Practice Address - Country:US
Practice Address - Phone:941-926-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2832171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist