Provider Demographics
NPI:1649425380
Name:GUAJARDO, STEPHANIE DALE (CNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DALE
Last Name:GUAJARDO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:SPAHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3598
Mailing Address - Country:US
Mailing Address - Phone:937-914-7067
Mailing Address - Fax:937-522-7513
Practice Address - Street 1:600 W MAIN ST STE 330
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3384
Practice Address - Country:US
Practice Address - Phone:937-429-7350
Practice Address - Fax:937-431-2623
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA10124NP363L00000X
OH10124363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOA10124NPOtherOHIO LICENSE
OH3077790Medicaid
OHH054460Medicare PIN
OHCOA10124NPOtherOHIO LICENSE