MEDICARE: STEPHANIE REQUENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1235801085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE REQUENA

Provider Business Mailing Address
First Line	:	PO BOX 5000
Second Line	:
City	:	SOUTHWEST HARBOR
State	:	ME
Zip	:	04679-5000
Country	:	US
Telephone Number	:	207-244-4678
Fax Number	:

Provider Business Practice Location Address
First Line	:	184 CLARK POINT RD
Second Line	:
City	:	SOUTHWEST HARBOR
State	:	ME
Zip	:	04679-4414
Country	:	US
Telephone Number	:	207-244-4678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2021
Last Update Date	:	09/30/2021

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Directions to “ STEPHANIE REQUENA ” Practice Location

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