Provider Demographics
NPI:1215185202
Name:MAYRANT, STEPHANIE RENEE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:MAYRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11204 WAPLES MILL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6036
Mailing Address - Country:US
Mailing Address - Phone:703-218-8500
Mailing Address - Fax:703-359-0463
Practice Address - Street 1:11204 WAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6036
Practice Address - Country:US
Practice Address - Phone:703-218-8500
Practice Address - Fax:703-359-0463
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012499992084P0800X
390200000X
VA010102499992084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program