Healthcare Provider Details

I. General information

NPI: 1134549561
Provider Name (Legal Business Name): STACY CAMIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 SW MICHIGAN ST
LAKE CITY FL
32025-0440
US

IV. Provider business mailing address

403 NW GIBSON LN
LAKE CITY FL
32055-1260
US

V. Phone/Fax

Practice location:
  • Phone: 386-487-0800
  • Fax:
Mailing address:
  • Phone: 386-697-4147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN 5214797
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: