Healthcare Provider Details

I. General information

NPI: 1104060458
Provider Name (Legal Business Name): JENNIFER DAWN STADDEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENIFER DAWN BRYSON MD

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 BEATRICE DR
PENSACOLA FL
32514-5867
US

IV. Provider business mailing address

9301 BEATRICE DR
PENSACOLA FL
32514-5867
US

V. Phone/Fax

Practice location:
  • Phone: 850-476-7555
  • Fax:
Mailing address:
  • Phone: 850-476-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME113553
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: