1891349775 NPI number — STEPHANIE MARIE VERGARA-MORALES

Table of content: STEPHANIE MARIE VERGARA-MORALES (NPI 1891349775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891349775 NPI number — STEPHANIE MARIE VERGARA-MORALES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERGARA-MORALES
Provider First Name:
STEPHANIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1891349775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
814 TYVOLA RD STE 126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28217-3539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
980-785-1113
Provider Business Mailing Address Fax Number:
980-785-1114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1944 WELLNESS BLVD,
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-785-1113
Provider Business Practice Location Address Fax Number:
980-785-1114
Provider Enumeration Date:
07/29/2019

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: 2355S0801X , with the licence number:  40915 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X , with the licence number: 1-24-78307 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com