Healthcare Provider Details

I. General information

NPI: 1881151496
Provider Name (Legal Business Name): STEPHANIE LAUREN WACHS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 33100
APO AE
09180-3100
US

IV. Provider business mailing address

UNIT 33100
APO AE
09180-3100
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-5762
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101270653
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number110522
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101270653
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: