Provider Demographics
NPI:1932801198
Name:MEDIAVILLA, STEPHANIE (AGACNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MEDIAVILLA
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19741 NW 7TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-3175
Mailing Address - Country:US
Mailing Address - Phone:786-768-4978
Mailing Address - Fax:
Practice Address - Street 1:19741 NW 7TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-3175
Practice Address - Country:US
Practice Address - Phone:786-768-4978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11025204207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine