Healthcare Provider Details

I. General information

NPI: 1992151013
Provider Name (Legal Business Name): STEPHANIE DUERKOPP FADDIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 S VULCAN AVE SUITE 201
ENCINITAS CA
92024-3600
US

IV. Provider business mailing address

1237 COLUMBUS WAY
VISTA CA
92081-8942
US

V. Phone/Fax

Practice location:
  • Phone: 626-555-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number16967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: