Provider Demographics
NPI:1902828460
Name:EDMONDSON CRUZ, STACY LEE (NP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEE
Last Name:EDMONDSON CRUZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 SE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-2329
Mailing Address - Country:US
Mailing Address - Phone:352-208-2833
Mailing Address - Fax:
Practice Address - Street 1:1490 SE MAGNOLIA EXT
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-4443
Practice Address - Country:US
Practice Address - Phone:352-512-9703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9225921363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P45432Medicare UPIN