MEDICARE: MS. STACY ANN THALASSITES NP-C

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	363LA2100X	Acute Care Nurse Practitioner	ARNP1709122	FL
2	363LF0000X	Family Nurse Practitioner	APRN1709122	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376650457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACY ANN THALASSITES NP-C

Provider Business Mailing Address
First Line	:	PO BOX 740861
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-0861
Country	:	US
Telephone Number	:	904-819-4539
Fax Number	:	904-819-4426

Provider Business Practice Location Address
First Line	:	100 WHETSTONE PL STE 105
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32086-5775
Country	:	US
Telephone Number	:	904-824-3777
Fax Number	:	904-824-6050

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

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	01/05/2026

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