Provider Demographics
NPI:1770998890
Name:ALLEN, STACCIE ANNE (NP)
Entity type:Individual
Prefix:MRS
First Name:STACCIE
Middle Name:ANNE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 NW 93RD ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-7146
Mailing Address - Country:US
Mailing Address - Phone:352-258-3726
Mailing Address - Fax:
Practice Address - Street 1:922 E CALL ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-3616
Practice Address - Country:US
Practice Address - Phone:904-368-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9203022363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012424100Medicaid
FLHV343YMedicare PIN