Healthcare Provider Details

I. General information

NPI: 1629464144
Provider Name (Legal Business Name): STEPHANIE VERMILLION PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 N 10TH ST STE B
PHOENIX AZ
85006-2710
US

IV. Provider business mailing address

1320 N 10TH ST STE B
PHOENIX AZ
85006-2710
US

V. Phone/Fax

Practice location:
  • Phone: 28-397-2856
  • Fax: 602-839-7272
Mailing address:
  • Phone: 602-839-7285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8761
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: