Healthcare Provider Details

I. General information

NPI: 1558729582
Provider Name (Legal Business Name): STEPHANIE BERROA LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

1183 IRONWOOD DR
GRAYSON GA
30017-1039
US

V. Phone/Fax

Practice location:
  • Phone: 678-209-2710
  • Fax:
Mailing address:
  • Phone: 203-509-8764
  • Fax: 678-212-6304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number16WOOOOOX
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: