Provider Demographics
NPI:1285815647
Name:WITFILL, STACY LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNN
Last Name:WITFILL
Suffix:
Gender:F
Credentials:DPM
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 2633
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34430-2633
Mailing Address - Country:US
Mailing Address - Phone:352-489-6621
Mailing Address - Fax:352-489-6920
Practice Address - Street 1:11786 CEDAR ST
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431-6770
Practice Address - Country:US
Practice Address - Phone:352-489-6621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2759213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65619Medicare PIN
FLU75367Medicare UPIN
FL4349910001Medicare NSC