Provider Demographics
NPI:1700234606
Name:BOATENG, STEPHANIE (CNM)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BOATENG
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4379 RIDGEWOOD CENTER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8323
Mailing Address - Country:US
Mailing Address - Phone:703-680-7950
Mailing Address - Fax:
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8323
Practice Address - Country:US
Practice Address - Phone:703-792-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367A00000X
VA0001239697163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse