Provider Demographics
NPI:1598062853
Name:FORAKER, STEPHANIE LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:FORAKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 STATE ROAD 13 N STE 21
Mailing Address - Street 2:
Mailing Address - City:FRUIT COVE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-2824
Mailing Address - Country:US
Mailing Address - Phone:904-239-5715
Mailing Address - Fax:
Practice Address - Street 1:445 STATE ROAD 13 N STE 21
Practice Address - Street 2:
Practice Address - City:FRUIT COVE
Practice Address - State:FL
Practice Address - Zip Code:32259-2824
Practice Address - Country:US
Practice Address - Phone:904-239-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206815225100000X
NCP20025225100000X
FLPT28730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist