Provider Demographics
NPI:1578205381
Name:CANAL, STEPHANIE NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:CANAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:046-974-1009
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKELAND HILLS BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:407-650-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2024-07-25
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant