Provider Demographics
NPI:1609227685
Name:STEWART, SUSAN E (LAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:STEWART
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 GROVE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:904-343-8899
Mailing Address - Fax:
Practice Address - Street 1:320 THIRD STREET
Practice Address - Street 2:SUTIE B
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266
Practice Address - Country:US
Practice Address - Phone:904-343-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1102171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist