MEDICARE: STACY MASTRO APRN

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	363LF0000X	Family Nurse Practitioner	RN193501	GA
2	363LF0000X	Family Nurse Practitioner	8445321-4405	UT
3	363L00000X	Nurse Practitioner	8445321-4405	UT
4	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1497284723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY MASTRO APRN

Provider Business Mailing Address
First Line	:	2429 MARTIN LUTHER KING JR DR SW # 4717
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-1713
Country	:	US
Telephone Number	:	404-691-9580
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 MORELAND AVE SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-1926
Country	:	US
Telephone Number	:	404-688-9300
Fax Number	:

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

Provider Enumeration Date	:	06/09/2017
Last Update Date	:	11/01/2025

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