Healthcare Provider Details

I. General information

NPI: 1023320884
Provider Name (Legal Business Name): STEPHANIE M. WORDES PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N HIGHLAND AVE NE
ATLANTA GA
30306-4614
US

IV. Provider business mailing address

1600 SW ARCHER RD BOX 112727
GAINESVILLE FL
32611-2727
US

V. Phone/Fax

Practice location:
  • Phone: 404-408-4744
  • Fax:
Mailing address:
  • Phone: 352-273-7002
  • Fax: 352-273-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008747
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2828
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113508
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: