MEDICARE: MRS. STACEY CERVANTES ARNP

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	363L00000X	Nurse Practitioner	ARNP1477082	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629077144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACEY CERVANTES ARNP

Provider Business Mailing Address
First Line	:	1140 SW BASCOM NORRIS DR STE 104
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-1329
Country	:	US
Telephone Number	:	386-719-6500
Fax Number	:	386-719-6503

Provider Business Practice Location Address
First Line	:	1140 SW BASCOM NORRIS DR STE 104
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-1329
Country	:	US
Telephone Number	:	386-719-6500
Fax Number	:	386-719-6503

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	10/10/2011

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