Provider Demographics
NPI:1386823250
Name:STEVENSON, KATIE ANNE (DOM)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANNE
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7012
Mailing Address - Country:US
Mailing Address - Phone:386-663-3003
Mailing Address - Fax:386-663-3007
Practice Address - Street 1:512 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7012
Practice Address - Country:US
Practice Address - Phone:386-663-3003
Practice Address - Fax:386-663-3007
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2276171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist