Provider Demographics
NPI:1831646108
Name:ESTEPHAN, INGRID (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:ESTEPHAN
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:INGRID
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:148 TIMBER CT
Mailing Address - Street 2:
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-1356
Mailing Address - Country:US
Mailing Address - Phone:877-219-6822
Mailing Address - Fax:877-219-6822
Practice Address - Street 1:2929 21ST AVE S APT 301
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-4515
Practice Address - Country:US
Practice Address - Phone:320-250-3019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-05
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4517363LA2100X, 363LA2200X, 363LG0600X
IL041461373363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology