Provider Demographics
NPI:1477865095
Name:DE L'ETOILE, STACIE
Entity type:Individual
Prefix:MS
First Name:STACIE
Middle Name:
Last Name:DE L'ETOILE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10506 MEDFORD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-0038
Mailing Address - Country:US
Mailing Address - Phone:813-252-0180
Mailing Address - Fax:813-489-4082
Practice Address - Street 1:10506 MEDFORD LAKE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-0038
Practice Address - Country:US
Practice Address - Phone:813-252-0180
Practice Address - Fax:813-489-4082
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PT256422251P0200X
FLPT25642225100000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY06TMOtherBC/BS OF FLORIDA
FL004070900Medicaid
FL002739900Medicaid
FL1477865095OtherAMERIGROUP