Provider Demographics
NPI:1104431543
Name:CAUDILL, STEPHANIE (APRN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CAUDILL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 CATHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9307
Mailing Address - Country:US
Mailing Address - Phone:859-338-2962
Mailing Address - Fax:
Practice Address - Street 1:1145 W LEXINGTON AVE STE C
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1290
Practice Address - Country:US
Practice Address - Phone:859-385-4093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013678207QA0401X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100703400Medicaid