Provider Demographics
NPI:1063032829
Name:STEPHENSON, MARIAH ANN
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ANN
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15137 DANVILLE AVE W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 BETHEL DR
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-6902
Practice Address - Country:US
Practice Address - Phone:651-315-3688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2021-06-28
Deactivation Date:2020-05-28
Deactivation Code:
Reactivation Date:2021-06-28
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program