Healthcare Provider Details

I. General information

NPI: 1861759466
Provider Name (Legal Business Name): STACY DEBRA KLINE LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 EDGEWATER BEACH DR
LAKELAND FL
33805-4737
US

IV. Provider business mailing address

1525 EDGEWATER BEACH DR
LAKELAND FL
33805-4737
US

V. Phone/Fax

Practice location:
  • Phone: 863-680-2229
  • Fax: 863-682-4784
Mailing address:
  • Phone: 863-680-2229
  • Fax: 863-682-4784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License NumberMW256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: