Healthcare Provider Details

I. General information

NPI: 1336523786
Provider Name (Legal Business Name): STACI BALKAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3599 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4252
US

IV. Provider business mailing address

2414 IRONWOOD DR
JACKSONVILLE FL
32216-2521
US

V. Phone/Fax

Practice location:
  • Phone: 904-345-7600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License NumberPT 29038
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: