Provider Demographics
NPI:1487879532
Name:DE SHANO WAKEMAN, STEPHANIE (DPT)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:DE SHANO WAKEMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13791 SAXON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2624
Mailing Address - Country:US
Mailing Address - Phone:606-306-9729
Mailing Address - Fax:
Practice Address - Street 1:13791 SAXON LAKE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2624
Practice Address - Country:US
Practice Address - Phone:609-306-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10037225100000X
MD27835225100000X
NJ40QA01013200225100000X
FL35468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist