Provider Demographics
NPI:1093324139
Name:BYNUM, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BYNUM
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 1:503 GEORGE BUSH DR W APT 2630
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2979
Mailing Address - Country:US
Mailing Address - Phone:619-762-0562
Mailing Address - Fax:
Practice Address - Street 1:503 GEORGE BUSH DR W APT 2630
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-2979
Practice Address - Country:US
Practice Address - Phone:619-762-0562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer