Provider Demographics
NPI:1366419251
Name:WILBORNE, STEPHANIE L (APRN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:WILBORNE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 GRAND AVE
Mailing Address - Street 2:FAIR HAVEN COMMUNITY HEALTH CENTER
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:203-777-8506
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:FAIR HAVEN COMMUNITY HEALTH CENTER
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-8506
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002941364SF0001X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily