Provider Demographics
NPI:1033516729
Name:STEPHENS, MICHAELA
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:STEPHENS
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 1:502 E HAPPY VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:CAVE CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42127-8845
Mailing Address - Country:US
Mailing Address - Phone:270-773-2090
Mailing Address - Fax:
Practice Address - Street 1:502 E HAPPY VALLEY ST
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:KY
Practice Address - Zip Code:42127-8845
Practice Address - Country:US
Practice Address - Phone:270-773-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist