Healthcare Provider Details

I. General information

NPI: 1437565413
Provider Name (Legal Business Name): STEPHANIE AHLGREN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 1ST ST N
WINTER HAVEN FL
33881-2476
US

IV. Provider business mailing address

950 COUNTY ROAD 17A W
AVON PARK FL
33825-2164
US

V. Phone/Fax

Practice location:
  • Phone: 863-292-4280
  • Fax: 863-292-4293
Mailing address:
  • Phone: 863-452-3060
  • Fax: 863-452-3069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND6941
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: