Provider Demographics
NPI:1710565130
Name:RODRIGUEZ, STEPHANIE LYNN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:RODRIGUEZ
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 1:701 W. 5TH STREET
Mailing Address - Street 2:SUITE 1229
Mailing Address - City:ODESSA, TX
Mailing Address - State:TX
Mailing Address - Zip Code:79763
Mailing Address - Country:US
Mailing Address - Phone:432-703-5238
Mailing Address - Fax:
Practice Address - Street 1:701 W 5TH STREET
Practice Address - Street 2:SUITE 1229
Practice Address - City:ODESSA, TX
Practice Address - State:TX
Practice Address - Zip Code:79763
Practice Address - Country:US
Practice Address - Phone:432-703-5238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10076331390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP10076331OtherPIT NUMBER