Provider Demographics
NPI:1467131961
Name:FAIRES, STEPHANIE MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:FAIRES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5500 E KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1607
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45617164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse