Provider Demographics
NPI:1811547094
Name:STOMBAUGH, TESSA MAE (CNM)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:MAE
Last Name:STOMBAUGH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8436 ARDENNES DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-4406
Mailing Address - Country:US
Mailing Address - Phone:317-407-4969
Mailing Address - Fax:
Practice Address - Street 1:8436 ARDENNES DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-4406
Practice Address - Country:US
Practice Address - Phone:317-407-4969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28213983A163W00000X
IL041.478085163W00000X
IN09000312A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse