Healthcare Provider Details

I. General information

NPI: 1811375918
Provider Name (Legal Business Name): CANDICE JOY STEPHENSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CANDICE JOY EISENMANN PA-C

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR SUITE 1601
JACKSONVILLE FL
32207-8334
US

IV. Provider business mailing address

PO BOX 41516
JACKSONVILLE FL
32203-1516
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-8060
  • Fax: 904-396-9700
Mailing address:
  • Phone: 904-202-5111
  • Fax: 904-396-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9108303
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: