Healthcare Provider Details

I. General information

NPI: 1750499349
Provider Name (Legal Business Name): STEPHANIE DYANE HOLLIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S OCEAN GRANDE DR UNIT 103
PONTE VEDRA BEACH FL
32082-4599
US

IV. Provider business mailing address

851 TRAFALGAR CT. SUITE 200E
MAITLAND FL
32751
US

V. Phone/Fax

Practice location:
  • Phone: 904-315-8765
  • Fax: 904-827-0485
Mailing address:
  • Phone: 407-667-0444
  • Fax: 407-667-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME90482
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: