MEDICARE: STACI GAUDIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN938301	FL

General Provider Information

NPI Number	:	1073103230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACI GAUDIN

Provider Business Mailing Address
First Line	:	805 N WHITTINGTON PKWY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-7101
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	26313 LIMESTONE SPRINGS WAY
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-6712
Country	:	US
Telephone Number	:	813-309-8886
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2021
Last Update Date	:	01/21/2021

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Directions to “ STACI GAUDIN ” Practice Location

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