Provider Demographics
NPI:1033673199
Name:ANDERSON, STEPHANIE (DC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132 BROAD WATER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-4338
Mailing Address - Country:US
Mailing Address - Phone:904-535-2178
Mailing Address - Fax:
Practice Address - Street 1:7807 BAYMEADOWS RD E STE 201
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9666
Practice Address - Country:US
Practice Address - Phone:904-306-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12708111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor