Healthcare Provider Details

I. General information

NPI: 1841340544
Provider Name (Legal Business Name): STACEY ALICIA VANDYKE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY ALICIA GOSS

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
USAF ACADEMY CO
80840-2502
US

IV. Provider business mailing address

311 MOONLIGHT BAY DR
PANAMA CITY BEACH FL
32407-2818
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5651
  • Fax:
Mailing address:
  • Phone: 205-306-5745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number530337
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9342364
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: