Provider Demographics
NPI:1952642191
Name:KING, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KING
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 1:11966 193RD LN NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1259
Mailing Address - Country:US
Mailing Address - Phone:763-276-5009
Mailing Address - Fax:763-441-4287
Practice Address - Street 1:21370 JOHN MILLESS DR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9449
Practice Address - Country:US
Practice Address - Phone:763-276-5009
Practice Address - Fax:763-441-4287
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist