Provider Demographics
NPI:1922036136
Name:FENLON, STEPHANIE L (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:L
Last Name:FENLON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 VAN DYKE RD STE 101B
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-8005
Mailing Address - Country:US
Mailing Address - Phone:813-960-4026
Mailing Address - Fax:813-443-8166
Practice Address - Street 1:4211 VAN DYKE RD STE 101B
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8005
Practice Address - Country:US
Practice Address - Phone:813-960-4026
Practice Address - Fax:813-443-8166
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261670000Medicaid
G82324Medicare UPIN