Provider Demographics
NPI:1083025332
Name:STURDEVANT, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:STURDEVANT
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 1:3600 VILLAGE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-6631
Mailing Address - Country:US
Mailing Address - Phone:402-875-9270
Mailing Address - Fax:402-875-9272
Practice Address - Street 1:3600 VILLAGE DR STE 110
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-6631
Practice Address - Country:US
Practice Address - Phone:402-875-9270
Practice Address - Fax:402-875-9272
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111649363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health