MEDICARE: STEPHANIE DALE GUAJARDO CNP

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	363L00000X	Nurse Practitioner	COA10124NP	OH
2	363LW0102X	Women's Health Nurse Practitioner	10124	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	COA10124NP	OTHER	OH	OHIO LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649425380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE DALE GUAJARDO CNP

Provider Business Mailing Address
First Line	:	2110 LEITER RD
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-3598
Country	:	US
Telephone Number	:	937-914-7067
Fax Number	:	937-522-7513

Provider Business Practice Location Address
First Line	:	600 W MAIN ST STE 330
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-3384
Country	:	US
Telephone Number	:	937-429-7350
Fax Number	:	937-431-2623

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

Provider Enumeration Date	:	11/21/2008
Last Update Date	:	03/08/2021

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