Provider Demographics
NPI:1912383043
Name:FIFER, STACY (ARNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:FIFER
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 1:1250 GRUMMAN PL STE B
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7927
Mailing Address - Country:US
Mailing Address - Phone:321-269-4240
Mailing Address - Fax:321-269-5248
Practice Address - Street 1:1250 GRUMMAN PL STE B
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7927
Practice Address - Country:US
Practice Address - Phone:321-269-4240
Practice Address - Fax:321-269-5248
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9309754363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner