Provider Demographics
NPI:1598859506
Name:VANDERHORST, STEPHANIE M (CNM MSN)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:M
Last Name:VANDERHORST
Suffix:
Gender:F
Credentials:CNM MSN
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:VANDERHORST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM MSN
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-927-0035
Mailing Address - Fax:260-927-0036
Practice Address - Street 1:510 SMALTZ WAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-0612
Practice Address - Country:US
Practice Address - Phone:260-927-0035
Practice Address - Fax:260-927-0036
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000099A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200421450Medicaid