MEDICARE: MS. STEPHANIE K HUMPHRIES L.M.E.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	FB9712840	FL

General Provider Information

NPI Number	:	1083929905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STEPHANIE K HUMPHRIES L.M.E.

Provider Business Mailing Address
First Line	:	4540 SOUTHSIDE BLVD
Second Line	:	SUITE 701
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5492
Country	:	US
Telephone Number	:	904-472-5563
Fax Number	:	904-435-4051

Provider Business Practice Location Address
First Line	:	4540 SOUTHSIDE BLVD
Second Line	:	SUITE 701
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5492
Country	:	US
Telephone Number	:	904-472-5563
Fax Number	:	904-435-4051

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2010
Last Update Date	:	08/16/2010

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