Provider Demographics
NPI:1760211528
Name:CARLSON, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CARLSON
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 1:1638 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1119
Mailing Address - Country:US
Mailing Address - Phone:208-401-4906
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1790
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44501-1790
Practice Address - Country:US
Practice Address - Phone:330-480-3444
Practice Address - Fax:330-480-5202
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53444390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program