Healthcare Provider Details

I. General information

NPI: 1417173832
Provider Name (Legal Business Name): STACI RENEE WALTERS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 02/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 S APOLLO BLVD
MELBOURNE FL
32901-1485
US

IV. Provider business mailing address

665 S APOLLO BLVD
MELBOURNE FL
32901-1485
US

V. Phone/Fax

Practice location:
  • Phone: 321-984-3200
  • Fax: 321-984-0032
Mailing address:
  • Phone: 321-984-3200
  • Fax: 321-984-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: