Provider Demographics
NPI:1083702716
Name:HERRICK, STEPHANIE LOUISE (FNP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LOUISE
Last Name:HERRICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7514
Mailing Address - Country:US
Mailing Address - Phone:928-575-6713
Mailing Address - Fax:
Practice Address - Street 1:1987 MCCULLOCH BLVD N
Practice Address - Street 2:STE 101
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5682
Practice Address - Country:US
Practice Address - Phone:928-453-6963
Practice Address - Fax:928-453-7011
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP328363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ144767Medicaid
AZ101878Medicare ID - Type Unspecified
AZ144767Medicaid