Provider Demographics
NPI:1891208195
Name:SOCCORSO, STEPHANIE NICHOLE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICHOLE
Last Name:SOCCORSO
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 1:1600 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5535
Mailing Address - Country:US
Mailing Address - Phone:727-344-1286
Mailing Address - Fax:
Practice Address - Street 1:1101 8TH AVE W
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-3809
Practice Address - Country:US
Practice Address - Phone:941-721-8681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59554183500000X
FLPSI35079390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes183500000XPharmacy Service ProvidersPharmacist