Provider Demographics
NPI:1760038202
Name:JODICE, STACEY L (DNP, FNP-BC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:JODICE
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 HYCREST RD
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-1568
Mailing Address - Country:US
Mailing Address - Phone:413-329-9017
Mailing Address - Fax:
Practice Address - Street 1:800 HUNTINGTON AVE FL 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6303
Practice Address - Country:US
Practice Address - Phone:617-525-9548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2294699207Q00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine