Provider Demographics
NPI:1710983564
Name:STEPHENS, CASSANDRA (MD)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 UBERMONKEY LN
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-5217
Mailing Address - Country:US
Mailing Address - Phone:270-465-0060
Mailing Address - Fax:270-465-0134
Practice Address - Street 1:70 UBERMONKEY LN
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-5217
Practice Address - Country:US
Practice Address - Phone:270-465-0060
Practice Address - Fax:270-465-0134
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2015-08-03
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
KY31329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64032014Medicaid
KY64032014Medicaid
H15543Medicare UPIN