Provider Demographics
NPI:1457921165
Name:ATHEA, STEPHANIE LOUISA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LOUISA
Last Name:ATHEA
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 1:87 S GRAND OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-4113
Mailing Address - Country:US
Mailing Address - Phone:786-523-5268
Mailing Address - Fax:
Practice Address - Street 1:867 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-3050
Practice Address - Country:US
Practice Address - Phone:626-375-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA714336164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse