Provider Demographics
NPI:1316217839
Name:STEPHENS, WAYNE (LAC, DAC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:LAC, DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 DAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-5712
Mailing Address - Country:US
Mailing Address - Phone:423-877-3770
Mailing Address - Fax:
Practice Address - Street 1:2805 DAYTON BLVD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-5712
Practice Address - Country:US
Practice Address - Phone:423-877-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-02
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACU000113171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist