Healthcare Provider Details

I. General information

NPI: 1548220239
Provider Name (Legal Business Name): WENDY H STEVENS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1697 KINGS RD UFJP COLLEGE PARK FAMILY PRACTICE CENTER
JACKSONVILLE FL
32209-6169
US

IV. Provider business mailing address

PO BOX 44008 UFJP PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-2251
  • Fax: 904-353-4479
Mailing address:
  • Phone: 904-244-3199
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3398
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: