Healthcare Provider Details

I. General information

NPI: 1972845329
Provider Name (Legal Business Name): STEPHANIE ANN STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 MARILYN DR
SULPHUR LA
70663-4029
US

IV. Provider business mailing address

310 MARILYN DR
SULPHUR LA
70663-4029
US

V. Phone/Fax

Practice location:
  • Phone: 337-515-9565
  • Fax:
Mailing address:
  • Phone: 337-515-9565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberCLP.200692-GEN
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: