Healthcare Provider Details

I. General information

NPI: 1720791106
Provider Name (Legal Business Name): STEPHANIE MARIE STEPHENS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11820 BEACH BLVD
JACKSONVILLE FL
32246-6670
US

IV. Provider business mailing address

11820 BEACH BLVD
JACKSONVILLE FL
32246-6670
US

V. Phone/Fax

Practice location:
  • Phone: 904-642-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11024528
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11024528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: