Provider Demographics
NPI:1366526873
Name:FITZGERALD, STACY DANAE (LMT)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:DANAE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:DANAE
Other - Last Name:GILLASPIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6412 LAKE SUZZANNE PL
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-3407
Mailing Address - Country:US
Mailing Address - Phone:850-867-9254
Mailing Address - Fax:850-481-0225
Practice Address - Street 1:508 AIRPORT RD
Practice Address - Street 2:SUITE I
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4030
Practice Address - Country:US
Practice Address - Phone:850-867-9254
Practice Address - Fax:850-481-0225
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA48416225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist