Provider Demographics
NPI:1225592470
Name:FANALE, STEPHANIE T (APRN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:T
Last Name:FANALE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:T
Other - Last Name:FLATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2499
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:1025 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2403
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:217-527-8194
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018667363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily