Provider Demographics
NPI:1609042530
Name:WENGEL, STEPHANIE LYN (MSPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYN
Last Name:WENGEL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SEERGREEN WAY
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-5529
Mailing Address - Country:US
Mailing Address - Phone:916-984-6354
Mailing Address - Fax:
Practice Address - Street 1:1301 E BIDWELL ST STE 201
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3452
Practice Address - Country:US
Practice Address - Phone:916-983-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist