Provider Demographics
NPI:1538585419
Name:O'BRIEN, STACY MARIE (APRN)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9680
Mailing Address - Fax:239-343-9685
Practice Address - Street 1:2780 CLEVELAND AVE STE 809
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5817
Practice Address - Country:US
Practice Address - Phone:239-343-9680
Practice Address - Fax:239-343-9685
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9278693364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010953400Medicaid