Provider Demographics
NPI:1356300578
Name:KISELJACK, STACY RAE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:RAE
Last Name:KISELJACK
Suffix:
Gender:F
Credentials:ARNP
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Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:1443 SAN MARCO BLVD
Practice Address - Street 2:UFJP PEDIATRIC CARDIOVASCULAR CENTER
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8565
Practice Address - Country:US
Practice Address - Phone:904-306-3962
Practice Address - Fax:904-493-2363
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP2744942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3040267-00Medicaid
FL500021964Medicare PIN
FL3040267-00Medicaid
FLE6635ZMedicare PIN
FLP46529Medicare UPIN