Provider Demographics
NPI:1629565080
Name:NEDZA, STEPHENNIE
Entity Type:Individual
Prefix:
First Name:STEPHENNIE
Middle Name:
Last Name:NEDZA
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 1:212 OSAGE ST
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-1770
Mailing Address - Country:US
Mailing Address - Phone:847-875-7043
Mailing Address - Fax:
Practice Address - Street 1:212 OSAGE ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-1770
Practice Address - Country:US
Practice Address - Phone:847-875-7043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056012471OtherOCCUPATIONAL THERAPIST