Provider Demographics
NPI:1992144612
Name:FALLEN-ELLIOTT, STEFFANY NICOLE
Entity type:Individual
Prefix:MRS
First Name:STEFFANY
Middle Name:NICOLE
Last Name:FALLEN-ELLIOTT
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 1:3826 CREIGHTON PL
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-9608
Mailing Address - Country:US
Mailing Address - Phone:706-394-8863
Mailing Address - Fax:
Practice Address - Street 1:3826 CREIGHTON PL
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-9608
Practice Address - Country:US
Practice Address - Phone:706-394-8863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-15
Last Update Date:2013-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1229G42480972171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor