Healthcare Provider Details

I. General information

NPI: 1578819074
Provider Name (Legal Business Name): MRS. STEPHANIE MONICA VANDELLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE MONICA KLUG

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5885 GLENRIDGE DR STE 200
ATLANTA GA
30328-5573
US

IV. Provider business mailing address

5885 GLENRIDGE DR STE 200
ATLANTA GA
30328-5573
US

V. Phone/Fax

Practice location:
  • Phone: 404-454-9715
  • Fax: 404-393-3739
Mailing address:
  • Phone: 404-454-9715
  • Fax: 404-393-3739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN188240
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: