Provider Demographics
NPI:1558947788
Name:CHENOWITH, STEPHANIE L (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:CHENOWITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:BRIDGEWATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-865-5146
Practice Address - Fax:317-865-5148
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011164A363LN0005X, 363LN0000X
IN28178176A163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300052746Medicaid