1629464144 NPI number — STEPHANIE VERMILLION PA-C, ATC

Table of content: STEPHANIE VERMILLION PA-C, ATC (NPI 1629464144)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629464144 NPI number — STEPHANIE VERMILLION PA-C, ATC

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
VERMILLION

Provider First Name:
STEPHANIE

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
PA-C, ATC

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:
1629464144

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
12/19/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1320 N 10TH ST STE B

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
PHOENIX

Provider Business Mailing Address State Name:
AZ

Provider Business Mailing Address Postal Code:
85006-2710

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
602-839-7285

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 N 10TH ST STE B

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
PHOENIX

Provider Business Practice Location Address State Name:
AZ

Provider Business Practice Location Address Postal Code:
85006-2710

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
28-397-2856

Provider Business Practice Location Address Fax Number:
602-839-7272

Provider Enumeration Date:
04/10/2015

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 363AM0700X , with the licence number: 8761 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .