Healthcare Provider Details

I. General information

NPI: 1043126469
Provider Name (Legal Business Name): STEPHANIE CANTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24008 135TH AVE
ROSEDALE NY
11422-1511
US

IV. Provider business mailing address

17441 126TH AVE
JAMAICA NY
11434-3313
US

V. Phone/Fax

Practice location:
  • Phone: 917-204-8475
  • Fax:
Mailing address:
  • Phone: 718-600-2246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number187149
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: