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General NPI Number Information
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NPI Number | 1639664717
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Entity Type | Individual
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Provider Name | STEPHANIE PHAN DO
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Gender | Female
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Dates
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Enumeration Date | 06/29/2018
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Last Update Date | 09/23/2024
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Provider Practice Location Address
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Address Line | 410 LIONEL WAY FL 3
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City | DAVENPORT
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State | FL
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Zip | 33837-7809
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Country | US
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Telephone | 863-293-1191
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Fax | 863-837-5333
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Provider Business Mailing Address
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Address Line | 500 E CENTRAL AVE
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City | WINTER HAVEN
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State | FL
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Zip | 33880-3094
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Country | US
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Telephone | 863-293-1191
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Fax | 863-837-5333
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | OS17951
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License Number State | FL
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