Provider Demographics
NPI:1003858986
Name:STANLEY, COURTNEY RENEE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:COURTNEY
Middle Name:RENEE
Last Name:STANLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14050 NW 14TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2865
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:601 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4213
Practice Address - Country:US
Practice Address - Phone:800-424-3672
Practice Address - Fax:954-377-3042
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004362363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCGDTMedicare ID - Type Unspecified
GAQ32156Medicare UPIN