Provider Demographics
NPI:1225505720
Name:WAMBACK, STEPHANIE
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:WAMBACK
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 1:20 GREEN ST # 2
Mailing Address - Street 2:
Mailing Address - City:DUDLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01571-3210
Mailing Address - Country:US
Mailing Address - Phone:141-371-7701
Mailing Address - Fax:
Practice Address - Street 1:20 GREEN ST # 2
Practice Address - Street 2:
Practice Address - City:DUDLEY
Practice Address - State:MA
Practice Address - Zip Code:01571-3210
Practice Address - Country:US
Practice Address - Phone:413-717-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist