Provider Demographics
NPI:1669422341
Name:LAVIANO, STACIE S (ARNP)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:S
Last Name:LAVIANO
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 1:12220 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-2631
Mailing Address - Country:US
Mailing Address - Phone:352-683-1982
Mailing Address - Fax:352-683-1077
Practice Address - Street 1:12220 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2631
Practice Address - Country:US
Practice Address - Phone:352-683-1982
Practice Address - Fax:352-683-1077
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2857552363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22622Medicare UPIN