Healthcare Provider Details

I. General information

NPI: 1831596550
Provider Name (Legal Business Name): STACY MAPLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12444 AGATITE RD
JACKSONVILLE FL
32258-2302
US

IV. Provider business mailing address

12444 AGATITE RD
JACKSONVILLE FL
32258-2302
US

V. Phone/Fax

Practice location:
  • Phone: 904-325-4911
  • Fax:
Mailing address:
  • Phone: 904-325-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number15451
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number4372
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: