Individual
STEPHANIE REGAN LACEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
841 PRUDENTIAL DR, UFJP PEDIATRIC CARDIOLOGY, JACKSONVILLE, FL 32207-8329
(904) 493-1610
(904) 493-2363
Mailing address
PO BOX 44008, UFJP PROVIDER ENROLLMENT, JACKSONVILLE, FL 32231-4008
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
OS9818
FL
2080P0202X
Pediatric Cardiology Physician
Primary
OS9818
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
109704014A
—
GA
05
—
2759861-00
—
FL
05
—
275986100
—
FL
Enumeration date
06/22/2006
Last updated
04/23/2010
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