Provider Demographics
NPI:1235801085
Name:REQUENA, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:REQUENA
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:PO BOX 5000
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04679-5000
Mailing Address - Country:US
Mailing Address - Phone:207-244-4678
Mailing Address - Fax:
Practice Address - Street 1:184 CLARK POINT RD
Practice Address - Street 2:
Practice Address - City:SOUTHWEST HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04679-4414
Practice Address - Country:US
Practice Address - Phone:207-244-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman