Healthcare Provider Details

I. General information

NPI: 1790211639
Provider Name (Legal Business Name): STEPHANIE KOMOROWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 WATERS AVE
SAVANNAH GA
31404-6220
US

IV. Provider business mailing address

28 LORRAINE ST
GLEN RIDGE NJ
07028-2028
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: