Provider Demographics
NPI:1760473334
Name:STIENSTRA, KATHLEEN L A (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L A
Last Name:STIENSTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:LYNN
Other - Last Name:AUEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1801 N 6TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-4097
Mailing Address - Country:US
Mailing Address - Phone:812-235-4867
Mailing Address - Fax:812-232-8059
Practice Address - Street 1:1801 N 6TH ST STE 600
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4097
Practice Address - Country:US
Practice Address - Phone:812-235-4867
Practice Address - Fax:812-232-8059
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038853207Q00000X, 171100000X
TXG5853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100368690Medicaid
IN854700ZZZZMedicare PIN
IN232420AMedicare PIN
IN100368690Medicaid
IN130910DMedicare PIN
IN941090X2Medicare PIN
IN252060IMedicare PIN