Provider Demographics
NPI:1205248309
Name:STEVENS, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:STEVENS
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 1:1102 A1A N
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4098
Mailing Address - Country:US
Mailing Address - Phone:904-273-6533
Mailing Address - Fax:904-273-6532
Practice Address - Street 1:1102 A1A N
Practice Address - Street 2:SUITE 104
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4098
Practice Address - Country:US
Practice Address - Phone:904-273-6533
Practice Address - Fax:904-273-6532
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9378669363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015285700Medicaid
FLIF241ZMedicare PIN