1407185010 NPI number — STEPHANIE LAUREN PACKRALL RD, LD, CLC

Table of content: STEPHANIE LAUREN PACKRALL RD, LD, CLC (NPI 1407185010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407185010 NPI number — STEPHANIE LAUREN PACKRALL RD, LD, CLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PACKRALL
Provider First Name:
STEPHANIE
Provider Middle Name:
LAUREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD, LD, CLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407185010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5640 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
NEW PORT RICHEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34652-2637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5640 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NEW PORT RICHEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34652-2637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-841-4425
Provider Business Practice Location Address Fax Number:
727-841-4222
Provider Enumeration Date:
12/10/2009

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: 133V00000X , with the licence number:  ND 5655 , 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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