Provider Demographics
NPI:1912789900
Name:SALAS, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SALAS
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 1:9169 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-2942
Mailing Address - Country:US
Mailing Address - Phone:623-233-6676
Mailing Address - Fax:
Practice Address - Street 1:9169 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-2942
Practice Address - Country:US
Practice Address - Phone:623-233-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ300744363LF0000X
AZRN208280163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse