Provider Demographics
NPI:1063258994
Name:REQUENA, STEVEN MARK ANTHONY (NP)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:MARK ANTHONY
Last Name:REQUENA
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 740861
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0861
Mailing Address - Country:US
Mailing Address - Phone:904-819-4539
Mailing Address - Fax:904-819-4906
Practice Address - Street 1:120 PALENCIA VILLAGE DR STE 107
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8553
Practice Address - Country:US
Practice Address - Phone:904-819-3200
Practice Address - Fax:904-819-3201
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY352149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily