Provider Demographics
NPI:1548847775
Name:THEODORE, STEPHANIE (LPN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WILLOWWOOD ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4040
Mailing Address - Country:US
Mailing Address - Phone:617-905-2489
Mailing Address - Fax:
Practice Address - Street 1:9 FORBES RD
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-2103
Practice Address - Country:US
Practice Address - Phone:781-838-6757
Practice Address - Fax:781-939-6968
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN86292164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse