Provider Demographics
NPI:1043044282
Name:ELLIOTT, STACY LYNN (CPS)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 COVENTRY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:228 E PINE ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4967
Practice Address - Country:US
Practice Address - Phone:863-581-7946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier