Provider Demographics
NPI:1437787066
Name:SULLENDER, STEPHANIE L (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:SULLENDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13504 STATE ROUTE 725
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45327-9766
Mailing Address - Country:US
Mailing Address - Phone:937-572-3068
Mailing Address - Fax:
Practice Address - Street 1:3500 W PURDUE AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-6357
Practice Address - Country:US
Practice Address - Phone:765-747-6090
Practice Address - Fax:765-747-5069
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10003029A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant