Provider Demographics
NPI:1346024569
Name:STEPHENS-BALLARD, PETRA KAY NICOLA
Entity Type:Individual
Prefix:MRS
First Name:PETRA KAY
Middle Name:NICOLA
Last Name:STEPHENS-BALLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 S CHAR MIL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-2802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 S CHAR MIL AVE
Practice Address - Street 2:
Practice Address - City:LAKE ALFRED
Practice Address - State:FL
Practice Address - Zip Code:33850-2802
Practice Address - Country:US
Practice Address - Phone:407-728-0409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9460123163W00000X
FLAPRN11028305363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse