Provider Demographics
NPI:1770742462
Name:WADE, STACY (NP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:LEMASTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3800
Mailing Address - Fax:239-343-3993
Practice Address - Street 1:2780 CLEVELAND AVE STE 819
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5817
Practice Address - Country:US
Practice Address - Phone:239-343-3800
Practice Address - Fax:239-343-3993
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28150715A363L00000X
IN71002094A363LF0000X
FLAPRN11012868363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200903990Medicaid
INP01307686OtherMEDICARE RR PTAN
FL112417400Medicaid