Provider Demographics
NPI:1114221439
Name:SULEWSKI, STEPHANIE DENISE (NCMA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DENISE
Last Name:SULEWSKI
Suffix:
Gender:F
Credentials:NCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MAD FOX DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-1124
Mailing Address - Country:US
Mailing Address - Phone:843-441-7408
Mailing Address - Fax:
Practice Address - Street 1:1063 USS TENNESSEE AVE
Practice Address - Street 2:AVENUE QL 11
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547-2606
Practice Address - Country:US
Practice Address - Phone:210-651-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6163771710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians