Provider Demographics
NPI:1518749290
Name:KIAI, STEPHEN M (APRN)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:KIAI
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-2129
Mailing Address - Fax:
Practice Address - Street 1:610 N MICHIGAN ST STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1081
Practice Address - Country:US
Practice Address - Phone:574-647-8120
Practice Address - Fax:574-647-8111
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28157595A163WC0200X
IN71014525A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300085229Medicaid