Provider Demographics
NPI:1275886756
Name:EALES, STEPHANIE K (CPM)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:K
Last Name:EALES
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-3311
Mailing Address - Country:US
Mailing Address - Phone:434-222-1139
Mailing Address - Fax:
Practice Address - Street 1:809 GROVE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-3311
Practice Address - Country:US
Practice Address - Phone:434-222-1139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-20
Last Update Date:2012-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0129000079176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife