Provider Demographics
NPI:1164722955
Name:GROSSO, STEPHANIE E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:E
Last Name:GROSSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEHANIE
Other - Middle Name:E
Other - Last Name:ORTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:375 N WALL ST, SUITE P620
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901
Mailing Address - Country:US
Mailing Address - Phone:815-933-8020
Mailing Address - Fax:815-933-8068
Practice Address - Street 1:375 N WALL ST, SUITE P620
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-933-8020
Practice Address - Fax:815-933-8068
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant