Provider Demographics
NPI:1104647429
Name:STEPHENSON MILLER, TESS GARRETT
Entity type:Individual
Prefix:
First Name:TESS
Middle Name:GARRETT
Last Name:STEPHENSON MILLER
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 1:7901 BARR RD
Mailing Address - Street 2:
Mailing Address - City:MYAKKA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34251-7206
Mailing Address - Country:US
Mailing Address - Phone:941-228-2655
Mailing Address - Fax:
Practice Address - Street 1:7901 BARR RD
Practice Address - Street 2:
Practice Address - City:MYAKKA CITY
Practice Address - State:FL
Practice Address - Zip Code:34251-7206
Practice Address - Country:US
Practice Address - Phone:941-228-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-19
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036081363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner