Provider Demographics
NPI:1144306192
Name:MITCHELL, STACI LIN (NP, APRN)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:LIN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:NP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:842 SUNSET LAKE BLVD STE 403
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7553
Practice Address - Country:US
Practice Address - Phone:941-485-3351
Practice Address - Fax:941-485-7677
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704179085363L00000X
FLAPRN9490434363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4476850Medicaid
MI4476850Medicaid