Provider Demographics
NPI:1518140722
Name:SODERSTROM, TEPHANIE D (PA)
Entity Type:Individual
Prefix:MRS
First Name:TEPHANIE
Middle Name:D
Last Name:SODERSTROM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16900 FRONT BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-2345
Mailing Address - Country:US
Mailing Address - Phone:850-234-1898
Mailing Address - Fax:850-234-7670
Practice Address - Street 1:16900 FRONT BEACH RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-2345
Practice Address - Country:US
Practice Address - Phone:850-234-1898
Practice Address - Fax:850-234-7670
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101738363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical