Provider Demographics
NPI:1205189107
Name:STEPHANOPOULOS, IRENE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:
Last Name:STEPHANOPOULOS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 DELANO DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-3338
Mailing Address - Country:US
Mailing Address - Phone:770-935-8616
Mailing Address - Fax:770-935-8549
Practice Address - Street 1:615 BEAVER RUIN RD NW STE B
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3401
Practice Address - Country:US
Practice Address - Phone:770-935-8616
Practice Address - Fax:770-935-8549
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN274593363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily