Provider Demographics
NPI:1700129723
Name:FENTER, STEPHANIE (LAC, DIPLAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FENTER
Suffix:
Gender:F
Credentials:LAC, DIPLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 MARINA VILLAGE PKWY STE 104
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1033
Practice Address - Country:US
Practice Address - Phone:601-201-4098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00010171100000X
152722171100000X
14671171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14671OtherCA STATE ACUPUNCTURE LICENSE
00010OtherMS ACUPUNCTURE LICENSE
152722OtherNCCAOM CERTIFICATION