Provider Demographics
NPI:1316228042
Name:GRUBB, STEPHANIE A (CST/CSFA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:GRUBB
Suffix:
Gender:F
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8433 HARCOURT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2190
Mailing Address - Country:US
Mailing Address - Phone:317-583-7702
Mailing Address - Fax:317-583-7601
Practice Address - Street 1:8433 HARCOURT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2190
Practice Address - Country:US
Practice Address - Phone:317-583-7702
Practice Address - Fax:317-583-7601
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN125727246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant