Provider Demographics
NPI:1255875472
Name:HENDERSHOTT, STACY KATHERINE (CNM)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:KATHERINE
Last Name:HENDERSHOTT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:661 E ALTAMONTE DR STE 318
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5103
Mailing Address - Country:US
Mailing Address - Phone:407-303-5204
Mailing Address - Fax:
Practice Address - Street 1:661 E ALTAMONTE DR STE 318
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5103
Practice Address - Country:US
Practice Address - Phone:407-303-5204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000282A367A00000X
MI4704338854367A00000X
FL11025853367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife