MEDICARE: STACY O'BRIEN AUDIOLOGY

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	231H00000X	Audiologist	L14000162663	FL

General Provider Information

NPI Number	:	1093105280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STACY O'BRIEN AUDIOLOGY

Provider Business Mailing Address
First Line	:	4624 RIVERWALK VILLAGE CT
Second Line	:
City	:	PONCE INLET
State	:	FL
Zip	:	32127-7261
Country	:	US
Telephone Number	:	813-767-0938
Fax Number	:

Provider Business Practice Location Address
First Line	:	1185 DUNLAWTON AVE
Second Line	:	SUITE 103
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2905
Country	:	US
Telephone Number	:	813-767-0938
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	STACY A O'BRIEN
Credential	:	AU.D.
Telephone Number	:	813-767-0938

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	01/27/2015

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