Provider Demographics
NPI:1174362800
Name:STEPHENS, DARYL ANDRE JR
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:ANDRE
Last Name:STEPHENS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 WILMORE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1456
Mailing Address - Country:US
Mailing Address - Phone:937-520-8303
Mailing Address - Fax:
Practice Address - Street 1:3691 WILMORE ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45416-1456
Practice Address - Country:US
Practice Address - Phone:937-520-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant