Healthcare Provider Details

I. General information

NPI: 1699086025
Provider Name (Legal Business Name): STEPHANIE TARA STANCEL CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE TARA WILSON CPNP

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 HARRISON RD
LOGANVILLE GA
30052-2462
US

IV. Provider business mailing address

1525 LAUREL CROSSING PKWY APARTMENT 202
BUFORD GA
30519-6562
US

V. Phone/Fax

Practice location:
  • Phone: 770-466-6112
  • Fax:
Mailing address:
  • Phone: 770-364-4061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN169676
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN169676
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: