Basic Information
| Provider Information | |||||||||
| NPI: | 1003140278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14909 HEALTH CENTER DR | ||||||||
| Address2: | 359 | ||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207161007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2403080809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14909 HEALTH CENTER DR | ||||||||
| Address2: | 359 | ||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207161007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2403080809 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | SA0057 | DC | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1265423016 | 01 | GROUP NPI | OTHER |