Provider Demographics
NPI:1831596550
Name:MAPLES, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MAPLES
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 1:12444 AGATITE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-2302
Mailing Address - Country:US
Mailing Address - Phone:904-325-4911
Mailing Address - Fax:
Practice Address - Street 1:12444 AGATITE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2302
Practice Address - Country:US
Practice Address - Phone:904-325-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15451247200000X
FL43722472E0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other