Provider Demographics
NPI:1083965156
Name:GERVATO-FAUVER, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GERVATO-FAUVER
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 1:78 W PARK AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-3560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 W LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-3422
Practice Address - Country:US
Practice Address - Phone:856-690-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00122900237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist