Provider Demographics
NPI:1104002849
Name:BEHRENS, STEPHANIE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BEHRENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MESSICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:160 WINDERMERE AVE APT 3501
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3938
Mailing Address - Country:US
Mailing Address - Phone:302-359-9892
Mailing Address - Fax:
Practice Address - Street 1:21 SOUTH RD STE 110
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2482
Practice Address - Country:US
Practice Address - Phone:860-284-4945
Practice Address - Fax:860-284-4946
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000601363AM0700X
CT3250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical