Provider Demographics
NPI:1194371799
Name:HART, STACIE LYNNETTE (LDO)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNNETTE
Last Name:HART
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 CURTIS BLVD STE 712
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-3965
Mailing Address - Country:US
Mailing Address - Phone:321-917-1125
Mailing Address - Fax:
Practice Address - Street 1:3770 CURTIS BLVD STE 712
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-3965
Practice Address - Country:US
Practice Address - Phone:321-917-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6514156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician