Healthcare Provider Details

I. General information

NPI: 1124471925
Provider Name (Legal Business Name): STEPHANIE PALMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2016
Last Update Date: 07/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39845 MAGNOLIA ST
LADY LAKE FL
32159-3448
US

IV. Provider business mailing address

39845 MAGNOLIA ST
LADY LAKE FL
32159-3448
US

V. Phone/Fax

Practice location:
  • Phone: 352-205-0884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1860
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: