Provider Demographics
NPI:1629077144
Name:CERVANTES, STACEY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:CERVANTES
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 1:1140 SW BASCOM NORRIS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1329
Mailing Address - Country:US
Mailing Address - Phone:386-719-6500
Mailing Address - Fax:386-719-6503
Practice Address - Street 1:1140 SW BASCOM NORRIS DR STE 104
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1329
Practice Address - Country:US
Practice Address - Phone:386-719-6500
Practice Address - Fax:386-719-6503
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1477082363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308846400Medicaid