Provider Demographics
NPI:1619230398
Name:RUIZ, STEPHANIE ANN
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANN
Last Name:RUIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:MARZAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 HENRIETTA ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-3120
Mailing Address - Country:US
Mailing Address - Phone:347-886-6013
Mailing Address - Fax:
Practice Address - Street 1:538 BROADHOLLOW RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3676
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1239559174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist