Provider Demographics
NPI:1760688212
Name:VAN HAM, STEPHANIE ANNE (FAMILY NURSE PRACTIT)
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:ANNE
Last Name:VAN HAM
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:17218 N 72ND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8581
Mailing Address - Country:US
Mailing Address - Phone:623-334-8670
Mailing Address - Fax:480-488-3189
Practice Address - Street 1:2025 N 3RD ST
Practice Address - Street 2:SUITE170
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1471
Practice Address - Country:US
Practice Address - Phone:602-462-1132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2532363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner