Provider Demographics
NPI:1174520928
Name:STEWART, CAROLYN COBB (ARNP, BC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:COBB
Last Name:STEWART
Suffix:
Gender:F
Credentials:ARNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 MANATEE SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-6442
Mailing Address - Country:US
Mailing Address - Phone:386-774-1380
Mailing Address - Fax:386-774-1380
Practice Address - Street 1:2239 S WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-8633
Practice Address - Country:US
Practice Address - Phone:386-279-0151
Practice Address - Fax:386-279-0148
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9194205363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL765193700Medicaid
FLU0709ZMedicare PIN
FL765193700Medicaid