Provider Demographics
NPI:1750796942
Name:FICKLER, STACY BETH (PA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:BETH
Last Name:FICKLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CLARENDON ST
Mailing Address - Street 2:UNIT 104
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6137
Mailing Address - Country:US
Mailing Address - Phone:973-495-9324
Mailing Address - Fax:
Practice Address - Street 1:2 CLARENDON ST
Practice Address - Street 2:UNIT 104
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-6137
Practice Address - Country:US
Practice Address - Phone:973-495-9324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant