1194043844 NPI number — MRS. STEPHANIE MARY TARRACCIANO D.O.

Table of content: MRS. STEPHANIE MARY TARRACCIANO D.O. (NPI 1194043844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194043844 NPI number — MRS. STEPHANIE MARY TARRACCIANO D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TARRACCIANO
Provider First Name:
STEPHANIE
Provider Middle Name:
MARY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHNEIDER
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194043844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3869 HIGHWAY 81
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGANVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30052-3918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-466-3622
Provider Business Mailing Address Fax Number:
770-466-3630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3869 HIGHWAY 81
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30052-3918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-466-3622
Provider Business Practice Location Address Fax Number:
770-466-3630
Provider Enumeration Date:
05/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  072138 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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