Provider Demographics
NPI:1760038202
Name:JODICE, STACEY L (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:JODICE
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CIRRUS DR APT 210
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-4462
Mailing Address - Country:US
Mailing Address - Phone:413-329-9017
Mailing Address - Fax:
Practice Address - Street 1:24 LYMAN ST STE 300
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1484
Practice Address - Country:US
Practice Address - Phone:508-366-7100
Practice Address - Fax:508-366-7303
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2294699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine