Provider Demographics
NPI:1194215244
Name:WILSON, STACY (APRN)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:MR
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:9973 58TH ST E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-4443
Mailing Address - Country:US
Mailing Address - Phone:808-979-6875
Mailing Address - Fax:
Practice Address - Street 1:333 TAMIAMI TRL S STE 101
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2425
Practice Address - Country:US
Practice Address - Phone:808-979-6875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9431499163WC0200X
FLAPRN9431499363LA2100X
HIAPRN-2822363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine