Provider Demographics
NPI:1720377807
Name:STEVENS, JOHNATHON KEVIN (LMT)
Entity Type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:KEVIN
Last Name:STEVENS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 PALM BAY RD NE
Mailing Address - Street 2:APT L 203
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-7620
Mailing Address - Country:US
Mailing Address - Phone:321-208-1316
Mailing Address - Fax:
Practice Address - Street 1:1900 PALM BAY RD NE
Practice Address - Street 2:SUITE D
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2955
Practice Address - Country:US
Practice Address - Phone:321-208-1316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59178171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor