Provider Demographics
NPI:1942663067
Name:VILLEDA, STEPHANIE (MED)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:VILLEDA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 73RD ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1704
Mailing Address - Country:US
Mailing Address - Phone:718-374-4030
Mailing Address - Fax:
Practice Address - Street 1:3123 73RD ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1704
Practice Address - Country:US
Practice Address - Phone:718-374-4030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist