Provider Demographics
NPI:1679684062
Name:STEVENS, STEPHANIE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 KENYON AVE
Mailing Address - Street 2:SUITE 326
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4239
Mailing Address - Country:US
Mailing Address - Phone:401-789-8543
Mailing Address - Fax:401-782-8766
Practice Address - Street 1:70 KENYON AVE
Practice Address - Street 2:SUITE 326
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4239
Practice Address - Country:US
Practice Address - Phone:401-789-8543
Practice Address - Fax:401-782-8766
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI00010363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0000000094OtherRHODE ISLAND BLUE CROSS/ BLUE SHIELD
RIID9000094Medicaid
RI000196OtherRHODE ISLAND BLUE CHIP
RIR56283Medicare UPIN
RI0000000094OtherRHODE ISLAND BLUE CROSS/ BLUE SHIELD