Healthcare Provider Details

I. General information

NPI: 1609329614
Provider Name (Legal Business Name): MARILYN STEPHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 SULLIVAN LN
SPARKS NV
89431-2815
US

IV. Provider business mailing address

1755 SULLIVAN LN
SPARKS NV
89431-2815
US

V. Phone/Fax

Practice location:
  • Phone: 775-355-7734
  • Fax:
Mailing address:
  • Phone: 775-355-7734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN09926
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: