Healthcare Provider Details

I. General information

NPI: 1700290244
Provider Name (Legal Business Name): EILEEN B STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

IV. Provider business mailing address

700 GOLD CUP DR
WARRENTON VA
20186-2373
US

V. Phone/Fax

Practice location:
  • Phone: 678-690-8334
  • Fax:
Mailing address:
  • Phone: 540-216-3477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number0001120258
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: