Healthcare Provider Details

I. General information

NPI: 1750940607
Provider Name (Legal Business Name): STEPHANIE PURMORT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2374 E PACIFICA PL
RANCHO DOMINGUEZ CA
90220-6214
US

IV. Provider business mailing address

3719 COUNTRY CLUB DR UNIT 16
LONG BEACH CA
90807-3151
US

V. Phone/Fax

Practice location:
  • Phone: 310-225-3221
  • Fax:
Mailing address:
  • Phone: 805-990-1734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License Number1198
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: