Provider Demographics
NPI:1750499349
Name:HOLLIS, STEPHANIE DYANE (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:DYANE
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:851 TRAFALGAR CT.
Mailing Address - Street 2:SUITE 200E
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:407-667-0444
Mailing Address - Fax:407-667-4338
Practice Address - Street 1:315 S OCEAN GRANDE DR
Practice Address - Street 2:UNIT 103
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4599
Practice Address - Country:US
Practice Address - Phone:904-315-8765
Practice Address - Fax:904-827-0485
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME90482207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269914100Medicaid
FL44844ZMedicare ID - Type Unspecified
FLI11879Medicare UPIN