Basic Information
| Provider Information | |||||||||
| NPI: | 1033770391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADENAX | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | CARLA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAMIREZ | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | CARLA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | STEPHANIE RAMIREZ | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7226 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914052003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182351414 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4952 WARNER AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926495506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145879007 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2019 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.