Healthcare Provider Details

I. General information

NPI: 1619579075
Provider Name (Legal Business Name): STEPHANIE POLANIA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STEPHANIE ARCHBOLD

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 10/12/2023
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4269 N. PINE ISLAND RD.
SUNRISE FL
33351-6044
US

IV. Provider business mailing address

4269 N. PINE ISLAND RD.
SUNRISE FL
33351-6044
US

V. Phone/Fax

Practice location:
  • Phone: 954-578-0200
  • Fax: 954-578-0050
Mailing address:
  • Phone: 954-578-0200
  • Fax: 954-578-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA9113707
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: