Provider Demographics
NPI:1750718805
Name:STACY, TERESA KAY
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:KAY
Last Name:STACY
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 1:12124 HIGH TECH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-8373
Mailing Address - Country:US
Mailing Address - Phone:888-300-5132
Mailing Address - Fax:
Practice Address - Street 1:12124 HIGH TECH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8373
Practice Address - Country:US
Practice Address - Phone:888-300-5132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2285524163W00000X
MO116943163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163W00000XNursing Service ProvidersRegistered Nurse