Provider Demographics
NPI:1164977286
Name:STATEN, STEPHANIE (CNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:STATEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:BLOCKBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-3811
Mailing Address - Fax:419-383-2918
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3811
Practice Address - Fax:419-383-2918
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008832363LF0000X
OHAPRN.CNP.020811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0244203Medicaid
SCNP4137Medicaid
NC1164977286Medicaid