Provider Demographics
NPI:1407202005
Name:STEPHANIE VANOVER, LLC
Entity Type:Organization
Organization Name:STEPHANIE VANOVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VANOVER
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:941-224-5009
Mailing Address - Street 1:3410 SIX FORKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7234
Mailing Address - Country:US
Mailing Address - Phone:919-832-3365
Mailing Address - Fax:
Practice Address - Street 1:3410 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7234
Practice Address - Country:US
Practice Address - Phone:919-832-3365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
NC837171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty