Provider Demographics
NPI:1508215450
Name:CENTENO, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:CENTENO
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 1:943 S BENEVA RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-2472
Mailing Address - Country:US
Mailing Address - Phone:941-379-1777
Mailing Address - Fax:941-379-1888
Practice Address - Street 1:943 S BENEVA RD STE 210
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232
Practice Address - Country:US
Practice Address - Phone:941-379-1777
Practice Address - Fax:941-379-1888
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014329363LF0000X
FLARNP9487298363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily