Provider Demographics
NPI:1508313180
Name:PARADISE, STACEY LYNN (ARNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:PARADISE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:CARE COORDINATION DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8202
Mailing Address - Fax:850-862-6148
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:CARE COORDINATION DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6796
Practice Address - Country:US
Practice Address - Phone:850-863-8202
Practice Address - Fax:850-862-6148
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9336344363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018711200Medicaid
FL35A2BOtherBCBSFL
FL018711200Medicaid