Provider Demographics
NPI:1184023780
Name:HAN, STEPHANIE BONGLAE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BONGLAE
Last Name:HAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 GOLDEN MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2271
Mailing Address - Country:US
Mailing Address - Phone:517-214-5304
Mailing Address - Fax:
Practice Address - Street 1:545 GOLDEN MEADOWS LN
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2271
Practice Address - Country:US
Practice Address - Phone:517-214-5304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA210849363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health