Healthcare Provider Details

I. General information

NPI: 1487402616
Provider Name (Legal Business Name): STEPHANIE COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4565 US HIGHWAY 17 STE 106
FLEMING ISLAND FL
32003-4822
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-4559
  • Fax: 904-269-4597
Mailing address:
  • Phone: 833-702-8383
  • Fax: 689-304-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9119509
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: