Provider Demographics
NPI:1639636194
Name:DEJNO, STEPHANIA
Entity Type:Individual
Prefix:
First Name:STEPHANIA
Middle Name:
Last Name:DEJNO
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 1:345 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-3923
Mailing Address - Country:US
Mailing Address - Phone:904-964-5455
Mailing Address - Fax:
Practice Address - Street 1:100 S LAWRENCE BLVD
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-9215
Practice Address - Country:US
Practice Address - Phone:352-473-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004024363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105481400Medicaid