Basic Information
Provider Information | |||||||||
NPI: | 1518160779 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCNALLY | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | SR. | ||||||||
Credential: | CST CFA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 909 SE 5TH AVE | ||||||||
Address2: | SUITE 201 | ||||||||
City: | DELRAY BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334835172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5619002498 | ||||||||
FaxNumber: | 8889724762 | ||||||||
Practice Location | |||||||||
Address1: | 4215 EDGEWATER DR | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328042206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075392000 | ||||||||
FaxNumber: | 4073980050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2007 | ||||||||
LastUpdateDate: | 10/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | N |   | Other Service Providers | Specialist |   | 246ZC0007X |   |   | Y |   | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
ID Information
ID | Type | State | Issuer | Description | F01487 | 01 | FL | NBSTSA CERT CST/CFA | OTHER |