Provider Demographics
NPI:1669666871
Name:HUDEPOHL, STACY ELLEN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ELLEN
Last Name:HUDEPOHL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ELLEN
Other - Last Name:NESMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4834 SOCIALVILLE FOSTER RD STE 60
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-6805
Mailing Address - Country:US
Mailing Address - Phone:513-229-8010
Mailing Address - Fax:513-229-8014
Practice Address - Street 1:4834 SOCIALVILLE FOSTER RD STE 60
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-6805
Practice Address - Country:US
Practice Address - Phone:513-561-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05759NM367A00000X
OHNM05795367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2260673Medicaid
OH2260673Medicaid