Provider Demographics
NPI:1073868303
Name:FRAZIER, STACY NICOLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICOLE
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 BAILEY DR STE 3
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2756
Mailing Address - Country:US
Mailing Address - Phone:850-460-9650
Mailing Address - Fax:
Practice Address - Street 1:113 BAILEY DR STE 3
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2756
Practice Address - Country:US
Practice Address - Phone:850-460-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001228415163W00000X
FLAPRN11012640363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1073868303Medicaid