Provider Demographics
NPI:1265429518
Name:PICKERING, STACEY E (ARNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:E
Last Name:PICKERING
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 S SUN DR STE 1003
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2573
Mailing Address - Country:US
Mailing Address - Phone:407-302-2620
Mailing Address - Fax:407-302-2690
Practice Address - Street 1:1071 S SUN DR STE 1003
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2573
Practice Address - Country:US
Practice Address - Phone:407-302-2620
Practice Address - Fax:407-302-2690
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9162428363LA2200X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3066398-00Medicaid
FLU4083ZMedicare ID - Type Unspecified
FLQ33107Medicare UPIN