Healthcare Provider Details

I. General information

NPI: 1073718664
Provider Name (Legal Business Name): STONE SURGERY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4417 US HWY 331 S
DEFUNIAK SPRINGS FL
32435-6703
US

IV. Provider business mailing address

4417 US HWY 331 S
DEFUNIAK SPRINGS FL
32435-6703
US

V. Phone/Fax

Practice location:
  • Phone: 850-951-4638
  • Fax: 850-951-4554
Mailing address:
  • Phone: 850-951-4638
  • Fax: 850-951-4554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3024682
License Number StateFL

VIII. Authorized Official

Name: DONNA WARD
Title or Position: OFFICE MANAGER
Credential:
Phone: 850-951-4638