Provider Demographics
NPI:1790250280
Name:ROE, STEPHANIE (FNP - BC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ROE
Suffix:
Gender:F
Credentials:FNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7828 AROSIA DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4044
Mailing Address - Country:US
Mailing Address - Phone:909-680-2909
Mailing Address - Fax:
Practice Address - Street 1:7515 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-1949
Practice Address - Country:US
Practice Address - Phone:818-947-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009835363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily