Healthcare Provider Details

I. General information

NPI: 1376650457
Provider Name (Legal Business Name): STACY ANN THALASSITES NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHETSTONE PL STE 105
SAINT AUGUSTINE FL
32086-5775
US

IV. Provider business mailing address

PO BOX 740861
ATLANTA GA
30374-0861
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-3777
  • Fax: 904-824-6050
Mailing address:
  • Phone: 904-819-4539
  • Fax: 904-819-4426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN1709122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: