=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376650457
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY ANN THALASSITES NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 02/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 WHETSTONE PL STE 105
-----------------------------------------------------
City | SAINT AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-5775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-3777
-----------------------------------------------------
Fax | 904-824-6050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 740861
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-0861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-819-4539
-----------------------------------------------------
Fax | 904-819-4426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN1709122
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------