Provider Demographics
NPI:1043765647
Name:WANNER, STEPHANIE
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:
Last Name:WANNER
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 1:404 LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:BLANDON
Mailing Address - State:PA
Mailing Address - Zip Code:19510-9651
Mailing Address - Country:US
Mailing Address - Phone:610-568-5714
Mailing Address - Fax:
Practice Address - Street 1:530 MACOBY ST
Practice Address - Street 2:
Practice Address - City:PENNSBURG
Practice Address - State:PA
Practice Address - Zip Code:18073-1112
Practice Address - Country:US
Practice Address - Phone:215-679-8076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program