Provider Demographics
NPI:1669721874
Name:FEATHERSTONE, STEPHANIE LYNNE (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNNE
Last Name:FEATHERSTONE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNNE
Other - Last Name:HENRIQUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3474
Mailing Address - Fax:239-343-2968
Practice Address - Street 1:2780 CLEVELAND AVE STE 702
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5857
Practice Address - Country:US
Practice Address - Phone:239-343-3474
Practice Address - Fax:239-343-2968
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106755363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007294800Medicaid
FLGQ272ZMedicare PIN