Basic Information
| Provider Information | |||||||||
| NPI: | 1023640646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEDDOM | ||||||||
| FirstName: | MACKENZIE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457251 | ||||||||
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| Practice Location | |||||||||
| Address1: | 463721 STATE ROAD 200 STE 7 | ||||||||
| Address2: | |||||||||
| City: | YULEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320978661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046026088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2020 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.