Provider Demographics
NPI:1437390291
Name:STEVENS, ETHEL HARRIET
Entity Type:Individual
Prefix:MRS
First Name:ETHEL
Middle Name:HARRIET
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ETHEL
Other - Middle Name:HARRIET
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12365 152ND ST N
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478-3558
Mailing Address - Country:US
Mailing Address - Phone:561-222-6503
Mailing Address - Fax:
Practice Address - Street 1:12365 152ND ST N
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33478-3558
Practice Address - Country:US
Practice Address - Phone:561-222-6503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23928849Medicaid