Provider Demographics
NPI:1003206962
Name:STEVENS, SAMANTHA JO (CRNA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:STEVENS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:DECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 16TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3510
Practice Address - Country:US
Practice Address - Phone:812-276-4378
Practice Address - Fax:812-275-1246
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28185263A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN940070017OtherMEDICARE
IN1102343973OtherANTHEM PTAN
IN201339310Medicaid
IN163460043OtherMEDICARE