Healthcare Provider Details

I. General information

NPI: 1306489950
Provider Name (Legal Business Name): STEPHANIE CONN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST STE 245
PARK RIDGE IL
60068-1126
US

IV. Provider business mailing address

1875 DEMPSTER ST STE 245
PARK RIDGE IL
60068-1126
US

V. Phone/Fax

Practice location:
  • Phone: 510-585-7546
  • Fax:
Mailing address:
  • Phone: 510-585-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number235837
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209.015652
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.397734
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9S089711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: