Provider Demographics
NPI:1417304221
Name:HUNTSMAN, STEPHANIE (MED, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HUNTSMAN
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9616 LIGHTHEART AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5517
Mailing Address - Country:US
Mailing Address - Phone:703-819-4414
Mailing Address - Fax:
Practice Address - Street 1:980 KELLY JOHNSON DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3785
Practice Address - Country:US
Practice Address - Phone:702-352-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-21
Last Update Date:2016-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05063702255A2300X
VA01260017462255A2300X
COAT.00010852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer