Provider Demographics
NPI:1407527401
Name:DUBOIS, STEPHANIE ANN MYRICK
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN MYRICK
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 E STATE ROAD 32
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8731
Mailing Address - Country:US
Mailing Address - Phone:317-867-4577
Mailing Address - Fax:
Practice Address - Street 1:3280 E STATE ROAD 32
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8731
Practice Address - Country:US
Practice Address - Phone:317-867-4577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011807A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily