Healthcare Provider Details

I. General information

NPI: 1306519731
Provider Name (Legal Business Name): STACIE DOLORES MALYSZKO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 10/26/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13547 BARKINGSIDE PLACE
SPRING HILL FL
34609
US

IV. Provider business mailing address

50 S B B KING BLVD # 100
MEMPHIS TN
38103-2626
US

V. Phone/Fax

Practice location:
  • Phone: 352-206-3423
  • Fax:
Mailing address:
  • Phone: 901-436-1381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11014470
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: