Provider Demographics
NPI:1841979580
Name:PALMER, STEFANIE DAJA
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:DAJA
Last Name:PALMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:DAJA
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1440 HILLSIDE PL SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-2573
Mailing Address - Country:US
Mailing Address - Phone:904-228-7993
Mailing Address - Fax:
Practice Address - Street 1:1440 HILLSIDE PL SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-2573
Practice Address - Country:US
Practice Address - Phone:904-228-7993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT014625225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist