Provider Demographics
NPI:1881847382
Name:FARMER, STACEY LEE (PA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:FARMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:AMARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PARKWAY N
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4127
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:841 EAST OAK STREET
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5838
Practice Address - Country:US
Practice Address - Phone:407-847-2050
Practice Address - Fax:407-847-9866
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9104661OtherMEDICAL LICENSE
FL000232000Medicaid