Healthcare Provider Details

I. General information

NPI: 1043734072
Provider Name (Legal Business Name): STEPHANIE RAY KERSHNER RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6851 DISTRIBUTION AVE S
JACKSONVILLE FL
32256
US

IV. Provider business mailing address

6851 DISTRIBUTION AVE S
JACKSONVILLE FL
32256-2742
US

V. Phone/Fax

Practice location:
  • Phone: 904-387-4481
  • Fax: 904-389-6965
Mailing address:
  • Phone: 904-387-4481
  • Fax: 904-389-6965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberTT16115
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: