Provider Demographics
NPI:1417630807
Name:MANDERSON, STACEY ANN
Entity Type:Individual
Prefix:
First Name:STACEY ANN
Middle Name:
Last Name:MANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 CALIGULA AVE SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-4754
Mailing Address - Country:US
Mailing Address - Phone:321-419-6945
Mailing Address - Fax:
Practice Address - Street 1:985 CALIGULA AVE SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-4754
Practice Address - Country:US
Practice Address - Phone:321-419-6945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker