Provider Demographics
NPI:1770363244
Name:STEPHENS, MIKAYLA J
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:J
Last Name:STEPHENS
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 1:12708 BRUCE B DOWNS BLVD
Mailing Address - Street 2:APT 1206
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612
Mailing Address - Country:US
Mailing Address - Phone:850-688-3432
Mailing Address - Fax:
Practice Address - Street 1:12708 BRUCE B DOWNS BLVD
Practice Address - Street 2:APT 1206
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:850-688-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL203S0010X2083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine