Provider Demographics
NPI:1649667833
Name:DAVIS, STEPHANIE MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:AMAYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1643 NW 136TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2857
Mailing Address - Country:US
Mailing Address - Phone:305-447-4150
Mailing Address - Fax:865-560-7088
Practice Address - Street 1:1643 NW 136TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2857
Practice Address - Country:US
Practice Address - Phone:305-447-4150
Practice Address - Fax:865-560-7088
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-25
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant