Provider Demographics
NPI:1881385797
Name:CUSTODIO, STEPHANIE CARMEN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CARMEN
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:CARMEN
Other - Last Name:VELEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1026 FALCON WAY
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-4469
Mailing Address - Country:US
Mailing Address - Phone:609-805-6509
Mailing Address - Fax:
Practice Address - Street 1:25 E BROAD ST
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2503
Practice Address - Country:US
Practice Address - Phone:856-459-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP04816700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse