Provider Demographics
NPI:1134657117
Name:STAMPEHL, KRISTEN SHAVAUGHN (NP-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:SHAVAUGHN
Last Name:STAMPEHL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:SHAVAUGHN
Other - Last Name:HONEYCUTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:1241 W. STADIUM BLVD.
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6023
Mailing Address - Country:US
Mailing Address - Phone:573-556-5771
Mailing Address - Fax:573-636-9756
Practice Address - Street 1:1241 W. STADIUM BLVD.
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:573-761-4351
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015980363LF0000X
MO2019000617363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420078166Medicaid