Healthcare Provider Details

I. General information

NPI: 1639718679
Provider Name (Legal Business Name): STACEY PETRA LOWE MSN, AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2019
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date: 12/21/2019
Reactivation Date: 03/20/2020

III. Provider practice location address

9468 SW 146TH PL
MIAMI FL
33186-1068
US

IV. Provider business mailing address

9468 SW 146TH PL
MIAMI FL
33186-1068
US

V. Phone/Fax

Practice location:
  • Phone: 305-776-5128
  • Fax:
Mailing address:
  • Phone: 305-776-5128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number11005119
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN11005119
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: