Healthcare Provider Details

I. General information

NPI: 1104020635
Provider Name (Legal Business Name): SHELLY ANN STEPENASKIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WOODWARD PL NE
ALBUQUERQUE NM
87102-2705
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-938-8296
  • Fax: 505-938-8688
Mailing address:
  • Phone: 505-272-1476
  • Fax: 505-938-8688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD 2009-0256
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberM6465
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number45585
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: