Provider Demographics
NPI:1639567902
Name:LAYNE, STEPHANIE JO (CST)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JO
Last Name:LAYNE
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:JO
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CST
Mailing Address - Street 1:1604 VISA DR.
Mailing Address - Street 2:STE. 2
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:309-846-4716
Mailing Address - Fax:309-454-7348
Practice Address - Street 1:1604 VISA DR.
Practice Address - Street 2:STE. 2
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-846-4716
Practice Address - Fax:309-454-7348
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL237.000148246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist