Healthcare Provider Details

I. General information

NPI: 1689027427
Provider Name (Legal Business Name): MISS STEPHANIE LAUREN HAUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 ALVARADO RD SUITE 308
SAN DIEGO CA
92120-5270
US

IV. Provider business mailing address

8583 AERO DR APT. 2088
SAN DIEGO CA
92123-1709
US

V. Phone/Fax

Practice location:
  • Phone: 619-265-7912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number53930
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: