Basic Information
| Provider Information | |||||||||
| NPI: | 1871049510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BULLOCK | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | SA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 833 CAMPBELL HILL ST NW STE 280 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704857628 | ||||||||
| FaxNumber: | 6784031081 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CAMPBELL HILL ST NW STE 280 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704857628 | ||||||||
| FaxNumber: | 6784031081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 06/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.