Provider Demographics
NPI:1003695115
Name:PIERDINOCK, STEPHANIE ROSE (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROSE
Last Name:PIERDINOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 5TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052-6003
Mailing Address - Country:US
Mailing Address - Phone:904-460-6681
Mailing Address - Fax:
Practice Address - Street 1:319 5TH AVE SW
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-6003
Practice Address - Country:US
Practice Address - Phone:904-460-6681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA91336225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist