Provider Demographics
NPI:1366919193
Name:WALDREP, STEPHANIE BROOKE (LVN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BROOKE
Last Name:WALDREP
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 BRAD ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-6651
Mailing Address - Country:US
Mailing Address - Phone:409-658-9458
Mailing Address - Fax:
Practice Address - Street 1:865 BRAD ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-6651
Practice Address - Country:US
Practice Address - Phone:409-658-9458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX345751164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse