Provider Demographics
NPI:1477988590
Name:STEFANSKI, JENELLE HALEY (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JENELLE
Middle Name:HALEY
Last Name:STEFANSKI
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:HALEY
Other - Last Name:STREFLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:6913 N MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8039
Practice Address - Country:US
Practice Address - Phone:574-647-6400
Practice Address - Fax:574-647-2951
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004799A363LF0000X
MI4704278821163W00000X
MI2013007660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201215000Medicaid
IN219570002Medicare PIN
IN201215000Medicaid