Provider Demographics
NPI:1750940607
Name:PURMORT, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PURMORT
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 1:3719 COUNTRY CLUB DR UNIT 16
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3151
Mailing Address - Country:US
Mailing Address - Phone:805-990-1734
Mailing Address - Fax:
Practice Address - Street 1:2374 E PACIFICA PL
Practice Address - Street 2:
Practice Address - City:RANCHO DOMINGUEZ
Practice Address - State:CA
Practice Address - Zip Code:90220-6214
Practice Address - Country:US
Practice Address - Phone:310-225-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1198246Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology