Provider Demographics
NPI:1881809465
Name:PANDULLO, STEPHANIE MICHELLE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:PANDULLO
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 1:2380 BROCKTON WAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-5459
Mailing Address - Country:US
Mailing Address - Phone:702-860-5617
Mailing Address - Fax:
Practice Address - Street 1:750 CORONADO CENTER DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5034
Practice Address - Country:US
Practice Address - Phone:702-564-4116
Practice Address - Fax:702-932-2403
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-903235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist