Provider Demographics
NPI:1871822452
Name:STEPHENS, MARY ANGELA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANGELA
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6204 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46816-3614
Mailing Address - Country:US
Mailing Address - Phone:260-447-7879
Mailing Address - Fax:
Practice Address - Street 1:6204 WINTER ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-3614
Practice Address - Country:US
Practice Address - Phone:260-447-7879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27038148A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse