Healthcare Provider Details

I. General information

NPI: 1962039461
Provider Name (Legal Business Name): STEPHANIE VAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 GILMORE AVE
LAKELAND FL
33805-3017
US

IV. Provider business mailing address

PO BOX 1559
BARTOW FL
33831-1559
US

V. Phone/Fax

Practice location:
  • Phone: 863-519-0575
  • Fax: 863-582-9251
Mailing address:
  • Phone: 863-519-0575
  • Fax: 863-582-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: