Provider Demographics
NPI:1538891502
Name:WAN, STEPHANIE O (MA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:O
Last Name:WAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13628 POMERADO RD APT 11
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-3535
Mailing Address - Country:US
Mailing Address - Phone:650-339-5045
Mailing Address - Fax:
Practice Address - Street 1:13628 POMERADO RD APT 11
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-3535
Practice Address - Country:US
Practice Address - Phone:650-339-5045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist