Provider Demographics
NPI:1629464144
Name:VERMILLION, STEPHANIE (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:VERMILLION
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N 10TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2710
Mailing Address - Country:US
Mailing Address - Phone:602-839-7285
Mailing Address - Fax:
Practice Address - Street 1:1320 N 10TH ST STE B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2710
Practice Address - Country:US
Practice Address - Phone:028-397-2856
Practice Address - Fax:602-839-7272
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
AZ8761363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer