Healthcare Provider Details

I. General information

NPI: 1902682651
Provider Name (Legal Business Name): JENNIFER MICHELLE STINE AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 E BAY DR
LARGO FL
33771-2213
US

IV. Provider business mailing address

12109 COUNTY ROAD 103
OXFORD FL
34484-2951
US

V. Phone/Fax

Practice location:
  • Phone: 727-441-1508
  • Fax:
Mailing address:
  • Phone: 727-441-1508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number11031233
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN11031233
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number9325658
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: