Provider Demographics
NPI:1114492691
Name:SWANSON, STEPHANIE NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICOLE
Other - Last Name:CLOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1225 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1016
Mailing Address - Country:US
Mailing Address - Phone:314-257-3760
Mailing Address - Fax:
Practice Address - Street 1:1225 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-257-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018194363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner