MEDICARE: STEPHANIE MELISSA HARRIS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	11019125	FL

General Provider Information

NPI Number	:	1396487567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE MELISSA HARRIS APRN

Provider Business Mailing Address
First Line	:	5191 FIRST COAST TECH PKWY FL 3
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-0609
Country	:	US
Telephone Number	:	904-223-3321
Fax Number	:	904-223-2169

Provider Business Practice Location Address
First Line	:	6100 SAINT JOHNS AVE STE 4
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-6859
Country	:	US
Telephone Number	:	904-223-3321
Fax Number	:	904-223-2169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2022
Last Update Date	:	07/24/2023

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