Provider Demographics
NPI:1942352802
Name:STACKHOUSE, JULIE R (CNM)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:R
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:R
Other - Last Name:MITCHENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2414 E STATE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4760
Practice Address - Country:US
Practice Address - Phone:260-422-7455
Practice Address - Fax:260-422-0086
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001177A363L00000X
IN09000127A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200847020Medicaid
IN000000595619OtherANTHEM
IN200847020Medicaid
IN000000514510OtherANTHEM
IN351972384 MQOtherSAGAMORE
IN000000595619OtherANTHEM