Provider Demographics
NPI:1497149264
Name:NZEAKOR, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:NZEAKOR
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 1:4111 23RD ST SW
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976
Mailing Address - Country:US
Mailing Address - Phone:407-233-5735
Mailing Address - Fax:
Practice Address - Street 1:3735 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901
Practice Address - Country:US
Practice Address - Phone:407-233-5735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11294224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant