Provider Demographics
NPI:1447876602
Name:PREVIC, STEPHANIE TAYLOR (FNP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:TAYLOR
Last Name:PREVIC
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-761-2128
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:1103 CIRCULO MERCADO
Practice Address - Street 2:
Practice Address - City:RIO RICO
Practice Address - State:AZ
Practice Address - Zip Code:85648-6248
Practice Address - Country:US
Practice Address - Phone:520-281-1550
Practice Address - Fax:520-281-1112
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ242881363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ079886Medicaid