Provider Demographics
NPI:1003140278
Name:WALL, STEPHANIE ANN (CSA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:WALL
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14909 HEALTH CENTER DR
Mailing Address - Street 2:359
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1007
Mailing Address - Country:US
Mailing Address - Phone:240-308-0809
Mailing Address - Fax:
Practice Address - Street 1:14909 HEALTH CENTER DR
Practice Address - Street 2:359
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1007
Practice Address - Country:US
Practice Address - Phone:240-308-0809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSA0057246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265423016OtherGROUP NPI