Basic Information
| Provider Information | |||||||||
| NPI: | 1649862699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 WARREN ST | ||||||||
| Address2: | |||||||||
| City: | ELLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124282216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456651054 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13802 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182062000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2021 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 318741-1 | NY | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.