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General NPI Number Information
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NPI Number | 1770796625
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Entity Type | Individual
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Provider Name | STACEY C AZZOLINO PA
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Gender | Female
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 02/23/2023
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Provider Practice Location Address
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Address Line | 12190 CORTEZ BLVD
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City | BROOKSVILLE
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State | FL
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Zip | 34613-5578
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Country | US
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Telephone | 352-597-1206
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Fax | 352-597-1208
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Provider Business Mailing Address
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Address Line | 12190 CORTEZ BLVD
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City | BROOKSVILLE
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State | FL
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Zip | 34613-5578
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Country | US
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Telephone | 352-597-1206
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Fax | 352-597-1208
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 009719-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 25MP00122900
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | PA9115496
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9115496
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License Number State | FL
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