Provider Demographics
NPI:1295243590
Name:LILLY, STACIE (ARNP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:LILLY
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 1:16975 SE 27TH PLACE RD
Mailing Address - Street 2:
Mailing Address - City:OCKLAWAHA
Mailing Address - State:FL
Mailing Address - Zip Code:32179-2323
Mailing Address - Country:US
Mailing Address - Phone:352-598-7662
Mailing Address - Fax:
Practice Address - Street 1:4600 SW 46TH CT
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-5708
Practice Address - Country:US
Practice Address - Phone:352-291-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-21
Last Update Date:2018-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9278130363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care