Provider Demographics
NPI:1841340544
Name:VANDYKE, STACEY ALICIA (CRNA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ALICIA
Last Name:VANDYKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ALICIA
Other - Last Name:GOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 MOONLIGHT BAY DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2818
Mailing Address - Country:US
Mailing Address - Phone:205-306-5745
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530337367500000X
FL9342364367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered