1871516559 NPI number — STEPHANIE RUTLEDGE WALLACE RPH

Table of content: STEPHANIE RUTLEDGE WALLACE RPH (NPI 1871516559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871516559 NPI number — STEPHANIE RUTLEDGE WALLACE RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
STEPHANIE
Provider Middle Name:
RUTLEDGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUTLEDGE
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871516559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14480 SW 37TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIRAMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33027-3790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-499-1713
Provider Business Mailing Address Fax Number:
954-499-1714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2216 HOLLYWOOD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33020-6702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-926-2914
Provider Business Practice Location Address Fax Number:
954-926-2957
Provider Enumeration Date:
07/25/2006

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: 183500000X , with the licence number:  PS21192 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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