Provider Demographics
NPI:1497301444
Name:VAN ROSSEM, STEPHANIE ANGELA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANGELA
Last Name:VAN ROSSEM
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 1:9901 164TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-4009
Mailing Address - Country:US
Mailing Address - Phone:718-551-4588
Mailing Address - Fax:
Practice Address - Street 1:28-18 ASTORIA BLVD, ASTORIA, NY 11102
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102
Practice Address - Country:US
Practice Address - Phone:917-410-6905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421399363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health