1700234606 NPI number — STEPHANIE BOATENG CNM

Table of content: STEPHANIE BOATENG CNM (NPI 1700234606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700234606 NPI number — STEPHANIE BOATENG CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOATENG
Provider First Name:
STEPHANIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
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:
1700234606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4379 RIDGEWOOD CENTER DR STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22192-8323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-680-7950
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4379 RIDGEWOOD CENTER DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22192-8323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-792-7300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2016

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: 367A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 0001239697 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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