Provider Demographics
NPI:1710435706
Name:STEVENS, NIESHA (PTA)
Entity Type:Individual
Prefix:
First Name:NIESHA
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-0033
Mailing Address - Country:US
Mailing Address - Phone:904-444-9622
Mailing Address - Fax:
Practice Address - Street 1:3599 N CANAL RD
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-4830
Practice Address - Country:US
Practice Address - Phone:904-444-9622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL347C00000X
FLPTA19702251E1200X
FLPTA19730225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No347C00000XTransportation ServicesPrivate Vehicle
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics