Provider Demographics
NPI:1386007227
Name:PACE, MARY JO (CST, SA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:PACE
Suffix:
Gender:F
Credentials:CST, SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RUE D ETRETAT
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2239
Mailing Address - Country:US
Mailing Address - Phone:256-541-4660
Mailing Address - Fax:
Practice Address - Street 1:4 RUE D ETRETAT
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2239
Practice Address - Country:US
Practice Address - Phone:256-541-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL131323282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital