Healthcare Provider Details

I. General information

NPI: 1134943012
Provider Name (Legal Business Name): STACEY PANICKER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 S FLAMINGO RD STE 101
DAVIE FL
33330-1902
US

IV. Provider business mailing address

15600 LANCE POINT PL
DAVIE FL
33331-3332
US

V. Phone/Fax

Practice location:
  • Phone: 954-312-3449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT25417
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: