Provider Demographics
NPI:1184138422
Name:RAFE, STEPHANIE NICHOLE (LPN)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:NICHOLE
Last Name:RAFE
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 1:201 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-2203
Mailing Address - Country:US
Mailing Address - Phone:618-201-8943
Mailing Address - Fax:
Practice Address - Street 1:201 S 17TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-2203
Practice Address - Country:US
Practice Address - Phone:618-201-8943
Practice Address - Fax:618-201-8943
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-23
Last Update Date:2017-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.124969164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse