Provider Demographics
NPI:1598132680
Name:STEPHAN, AMANDA RENEE (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-4749
Mailing Address - Country:US
Mailing Address - Phone:760-594-9100
Mailing Address - Fax:866-886-7824
Practice Address - Street 1:1463 S 4TH ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4749
Practice Address - Country:US
Practice Address - Phone:760-594-9100
Practice Address - Fax:866-886-7824
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA731020163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse