Provider Demographics
NPI:1083929905
Name:HUMPHRIES, STEPHANIE K (LME)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:K
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:LME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 SOUTHSIDE BLVD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5492
Mailing Address - Country:US
Mailing Address - Phone:904-472-5563
Mailing Address - Fax:904-435-4051
Practice Address - Street 1:4540 SOUTHSIDE BLVD
Practice Address - Street 2:SUITE 701
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5492
Practice Address - Country:US
Practice Address - Phone:904-472-5563
Practice Address - Fax:904-435-4051
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFB9712840174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty