Provider Demographics
NPI:1336328673
Name:FESSETTE, STACIE QUINN (DPM)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:QUINN
Last Name:FESSETTE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2835 W DE LEON ST
Mailing Address - Street 2:SUITE #101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4130
Mailing Address - Country:US
Mailing Address - Phone:813-254-6592
Mailing Address - Fax:813-254-3634
Practice Address - Street 1:2835 W DE LEON ST
Practice Address - Street 2:SUITE #101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4130
Practice Address - Country:US
Practice Address - Phone:813-254-6592
Practice Address - Fax:813-254-3634
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3325213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65A03OtherBCBS
FLCQ633ZOtherMEDIARE PTAN
CQ633YOtherMEDICARE PTAN
FLP00829933OtherRR MEDICARE
FL1336328673Medicare NSC