=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750499349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE DYANE HOLLIS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2006
-----------------------------------------------------
Last Update Date | 07/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 S OCEAN GRANDE DR UNIT 103
-----------------------------------------------------
City | PONTE VEDRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-4599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-315-8765
-----------------------------------------------------
Fax | 904-827-0485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 851 TRAFALGAR CT. SUITE 200E
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-667-0444
-----------------------------------------------------
Fax | 407-667-4338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | ME90482
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------