Provider Demographics
NPI:1285262659
Name:TIMMES, STEPHANIE ELLEN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELLEN
Last Name:TIMMES
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 1:110 HUNNEWELL AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 HUNNEWELL AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-2710
Practice Address - Country:US
Practice Address - Phone:516-775-7407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY025942363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program