Provider Demographics
NPI:1629506274
Name:STALLWORTH, DEMETRIUS
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 VINEYARD LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-7678
Mailing Address - Country:US
Mailing Address - Phone:904-233-2008
Mailing Address - Fax:
Practice Address - Street 1:490 VINEYARD LN
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-7678
Practice Address - Country:US
Practice Address - Phone:904-233-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5192381164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse