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General NPI Number Information
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NPI Number | 1114660206
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Entity Type | Individual
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Provider Name | STEPHANIE PONCE MAT, LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 04/15/2022
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Last Update Date | 08/18/2023
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Provider Practice Location Address
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Address Line | 5523 WINTER GARDEN VINELAND RD
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City | WINDERMERE
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State | FL
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Zip | 34786-6097
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Country | US
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Telephone | 407-347-0980
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Fax |
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Provider Business Mailing Address
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Address Line | 7312 GOLDENPOINTE BLVD APT 108
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City | ORLANDO
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State | FL
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Zip | 32807-6146
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Country | US
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Telephone | 561-506-6634
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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