Healthcare Provider Details

I. General information

NPI: 1437636503
Provider Name (Legal Business Name): STEFANIE LEA EADS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 01/14/2023
Certification Date: 01/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S RIDGEWOOD AVE
EDGEWATER FL
32132-2333
US

IV. Provider business mailing address

1000 S RIDGEWOOD AVE
EDGEWATER FL
32132-2333
US

V. Phone/Fax

Practice location:
  • Phone: 386-220-8222
  • Fax:
Mailing address:
  • Phone: 386-220-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024176384
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: