Provider Demographics
NPI:1518246669
Name:KING, STEPHANIE G (CRNP)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:G
Last Name:KING
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:G
Other - Last Name:BIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:307 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:PA
Mailing Address - Zip Code:18810-1710
Mailing Address - Country:US
Mailing Address - Phone:570-888-1541
Mailing Address - Fax:570-888-2380
Practice Address - Street 1:307 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:PA
Practice Address - Zip Code:18810-1710
Practice Address - Country:US
Practice Address - Phone:570-888-1541
Practice Address - Fax:570-888-2380
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011532363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026337300001Medicaid
PA2664595OtherHIGHMARK BLUE SHIELD
PA828418OtherFIRST PRIORITY HEALTH
PA9611934OtherAETNA
PAP01121684Medicare PIN