Provider Demographics
NPI:1407901051
Name:TWENHAFEL, STACY ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:ANNE
Last Name:TWENHAFEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9754
Practice Address - Street 1:1351 HICKORY POINT DR
Practice Address - Street 2:SUITE B
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-1098
Practice Address - Country:US
Practice Address - Phone:217-875-3724
Practice Address - Fax:217-875-3840
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009713Medicaid
IL046009713Medicaid