Provider Demographics
NPI:1538534177
Name:BURDETTE, STEPHANIE ANN (AT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:BURDETTE
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 CAMARO CT
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-9793
Mailing Address - Country:US
Mailing Address - Phone:937-510-1303
Mailing Address - Fax:
Practice Address - Street 1:1243 CAMARO CT
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-9793
Practice Address - Country:US
Practice Address - Phone:937-510-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0029862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer