Healthcare Provider Details

I. General information

NPI: 1417874074
Provider Name (Legal Business Name): STACI R MIMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 RESERVOIR RD NW
WASHINGTON DC
20007-2111
US

IV. Provider business mailing address

5229 MILLENIA BLVD APT 104
ORLANDO FL
32839-6145
US

V. Phone/Fax

Practice location:
  • Phone: 202-687-0100
  • Fax:
Mailing address:
  • Phone: 559-392-4531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN959015
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: