1548723000 NPI number — STEPHANIE NICHOLE O'CONNOR PNP

Table of content: STEPHANIE NICHOLE O'CONNOR PNP (NPI 1548723000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548723000 NPI number — STEPHANIE NICHOLE O'CONNOR PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'CONNOR
Provider First Name:
STEPHANIE
Provider Middle Name:
NICHOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
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:
1548723000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 N F AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85607-1920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-364-6852
Provider Business Mailing Address Fax Number:
520-364-4261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 S OCOTILLO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85602-6406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-586-4040
Provider Business Practice Location Address Fax Number:
520-364-4261
Provider Enumeration Date:
04/11/2019

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: 363LP0200X , with the licence number:  224631 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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