Provider Demographics
NPI:1720716988
Name:WANLASS, STEPHANIE SUE (AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:SUE
Last Name:WANLASS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:745 ROUTE 25A STE A
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-6603
Mailing Address - Country:US
Mailing Address - Phone:631-821-0200
Mailing Address - Fax:631-821-5721
Practice Address - Street 1:745 ROUTE 25A STE A
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-6603
Practice Address - Country:US
Practice Address - Phone:631-821-0200
Practice Address - Fax:631-821-5721
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY589857163WM0705X
NY310780363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical