Provider Demographics
NPI:1699035329
Name:MACKALL, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MACKALL
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 1:1787 LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-1038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:335 W. MCKINELY WAY
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-1038
Practice Address - Country:US
Practice Address - Phone:330-757-2732
Practice Address - Fax:330-757-2756
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4425174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist