Provider Demographics
NPI:1013111939
Name:TICHENOR, STEPHANIE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:TICHENOR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:210 E GRAY ST STE 1105
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3907
Practice Address - Country:US
Practice Address - Phone:502-583-1697
Practice Address - Fax:502-583-2120
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1096981163WG0000X
KY5412P363L00000X
KY3005412363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY093360OtherSIHO- NNIKY
KY7100040710Medicaid
KYP00948802OtherRAILROAD MEDICARE
IN200884950Medicaid
KY50031587OtherPASSPORT- NNIKY
KY000000696981OtherANTHEM- NNIKY
KY000040710OtherHUMANA- NNIKY
KY8960504OtherCIGNA- NNIKY
KY9152454OtherAETNA- NNIKY
KYP400041216Medicare PIN