Provider Demographics
NPI:1780952168
Name:STEFANGO, JAMIE (PTA)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:STEFANGO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W POE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 W POE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-1219
Practice Address - Country:US
Practice Address - Phone:419-352-7558
Practice Address - Fax:419-354-9501
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.07850172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker