Provider Demographics
NPI:1801533054
Name:CLEMMONS, STACY NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:NICOLE
Last Name:CLEMMONS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 PARSON ST
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120-5317
Mailing Address - Country:US
Mailing Address - Phone:352-362-2583
Mailing Address - Fax:
Practice Address - Street 1:1726 MEDICAL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1426
Practice Address - Country:US
Practice Address - Phone:239-624-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11019722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114765000Medicaid
FLKI8LIOtherBCBS