Provider Demographics
NPI:1609391903
Name:ICE, STEPHANIE DAWN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DAWN
Last Name:ICE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 952
Mailing Address - Street 2:
Mailing Address - City:BARRACKVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26559-0952
Mailing Address - Country:US
Mailing Address - Phone:304-816-6000
Mailing Address - Fax:
Practice Address - Street 1:227 MEDICAL PARK DR STE 103
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9038
Practice Address - Country:US
Practice Address - Phone:681-342-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN75904-FNP-BC363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner